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`TVENTORY RECONCILIATIC ,� "' e <br />kJJ'arrERLY SUMMARY REPORT FORM .0.11 <br />SEP 16 14,901 <br />Raw. ►zjY Yrti� <br />Facility Address: 385 W. C antlina gd <br />Trac;. Calif. 95376 <br />Telephone: _(209) 835-89?0 <br />Person Filing <br />Report: Kenneth W. Mi11iPan 44667 <br />aI 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 />j -j Inventory variations exceeded the allowable limits for this <br />LL. -11 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 all variations and the reason <br />for exceeding the allowable limits. <br />Date <br />1. <br />2. <br />3. <br />4. <br />5. <br />Tank <br />Amount <br />Reason <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 />July ------------>September <br />ter 4 - October --------->December <br />Send to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION <br />-7 <br />P.O. Box 2009 <br />Stockton, CA 95201 <br />(209) 468-3420 <br />EH 23 019 (10/89) <br />