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Facility Name: <br />Facility Address: <br />INVENTORY RECONCILIATI" <br />%%.W QUARTERLY SUMMARY REPORT i1iRM <br />Telephone: "'(,=' _ <br />Person Filing A <br />Report: <br />I <br />1� 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 all variations and the reason <br />for exceeding the allowable limits. <br />Date Tanker Amount; FReason <br />a Pfd. <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 quarterly summary report shall be submitted within fiil%eeeen (15) days of <br />the end of each quarter. Circle appropriate qua ter. <br />Quarter 1 - Januar >Marc Ir q�✓ <br />January t4, 0;J, 4g <br />Quarter 2 - April ----------->June cn ��Icr <br />uar - July------------>SeptembjtT�s�T�� ^7_. <br />uarter October --------->December F�y`�S�CTjy <br />Send to: SAN JOAQUIN PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION <br />1601 E. Hazelton Ave., P.O. Box 2009 <br />Stockton, CA 96201 <br />(209) 468-3420 <br />