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,1W <br />Facility Name: <br />• <br />• <br />INVENTORY RECONCILIATION <br />QUARTERLY SUMMARY REPORT FORM <br />/ r kyr fl�rl.z Tank if I <br />• � \.A L1 V�}L <br />L� • r -u Ia W'f✓ <br />JUL 17 iom <br />ENVIRONMENTAL HEALTH <br />PERMIT/SERVICES <br />Facility Address: 2-'731- <br />.0 64 �2 L <br />Telephone: ,0 ) <br />Person Filin <br />Report: <br />I hereby certify under penalty of perjury that all inventory <br />variations for the above mentioned facility were within the <br />allowable limits for this quarter. (No in column 13 of the <br />Inventory Reconciliation Sheet.) <br />Inventory variations exceeded the allowable limits for this <br />quarter. I hereby certify under penalty of perjury that the <br />source for the variation was not due to authorized (leak) <br />release. (Yes in Column 13 of the Inventory Reconciliation <br />Sheet) . <br />List date, tank #, amount for al variations and the reason <br />for exceeding the allowable limits. <br />Date Tank Amount Reason <br />1. `L. <br />2. <br />3. <br />4. Ii�1I <br />f� <br />,I. <br />&Vkl 7,11,: <br />Additional dates/amounts shall be continued on a separate <br />sheet of paper and attached. <br />If the source of the variation which exceeded allowable limits <br />was due to a leak, the incident shall be reported to Public <br />Health Services of San Joaquin County.Environmental Health <br />Division, within tTAenty-four (24) hours and an unauthorized <br />release report submitted. <br />The quarterly summary report shall be submitted within fifteen (15) days of <br />the end of each quarter. Circle appropriate quarter. <br />Quarter 1 - January ---------- >March <br />Quarter 2 - April ----------->June <br />Quarter 3 - July ------------>September <br />Quarter 4 - October ---------->December <br />Send to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION <br />.1601 E. Hazelton Ave., P.O. Box 2009 <br />Stockton, CA 95201 <br />(209) 468-3420 <br />EH 23 019 (10/a9) <br />