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A <br />Facility Name: <br />I <br />NVENTORY RECONCILIATION <br />QUARTERLY SUMMARY REPORT FORM <br />-fu1t <br />Facility Address: 2?2T' c:.00 y, <br />Telephone: ?--K <br />Person Filing ^rte <br />Report: -rrx c 4W I <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 />a� <br />aist date, tank #, amount for all variations and the reason <br />or exceeding the allowable limits. <br />SSP U 1 1992 Date <br />ENVIRONMENTAL RMIT/SERV1 ES 1H <br />2. <br />3. <br />4. <br />5, <br />Tank <br />Amount <br />Re— anon <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 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 />1501 E. Hazelton Ave., P.O. Box 2009 <br />Stockton, CA 95201 <br />EH 23 019 (10/89) (209) 468-3420 <br />