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INVENTORY RECONCILI TON <br />VV QUARTERLY SUMMARY REP62W FORM <br />Facility Name: VAP -V WO6 Qn!'` <br />Facility Address: 0/0' u)� <br />Telephone: /66 77 <br />Person Filiog , <br />Report: +tiw+ <br />JWr 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 />12 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 all variations and the reason <br />for exceeding the allowable limits. <br />Date Tank # Amount <br />2. btr <br />3. a <br />4. <br />5. <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 c: <br />the end of each quarter. Circle appropriate quarter. <br />Quarter 1 - January ---------- >March <br />April ----------->June <br />Quarter - July ------------>September <br />r er 4 - October ---------->December <br />Send to: SAN JOAQUIN PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION <br />1601 E. Hazelton Ave., P.O. Box 2009 + <br />Stockton, CA 9b�01 <br />(209) 468-3420 <br />