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IDINVENTORY.RECONCILIATION 9 <br />QUARTERLY SUMMARY REPORT FORM <br />Facility Name: <br />Facility Address: _U2,'�� <br />�r A)-- c i <br />Telephone: ?Xxr <br />Person Filing <br />Report: S11 rr,"'Jot <br />'T'ank ;9 Size Product <br />/lolelw%'. <br />Z Xh) <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 J, amount for all variations and the reason <br />for exceeding the allowable limits. <br />Date Tank Amount Reason <br />1. <br />2. <br />3. <br />4. <br />5. <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 twenty-four (24) hours and an unauthorized <br />release report submitted.- <br />The <br />ubmitted: <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 />�`, uar' -2 -- April ------------>June <br />Quarter 3 - July ------------->September <br />Quarter 4 - October ---------->December <br />r <br />RECEIVE;U <br />J U L 1 1991 <br />ENVIRONMENTAL HEALTH <br />PERMIT/SERVICES <br />Send to: SAN JOAQUIN 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 />