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INVENTORY RECONCIL'IATI-F1 <br />%..W INVENTORY <br />SUMMARY REPORT FORM <br />f `Facility Name: 041)2'/ wo-, JJ� <br />Facility Address: x`10/ u/, <br />Telephone: 'l6( <br />Person Filim , <br />Report: I'vv , AA, c �cQ <br />1k► 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 />Q 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 f, amount for all variations and the reason <br />for exceeding the allowable limits. <br />1. <br />2. <br />3. <br />4. <br />5. <br />DateTank Amount <br />10a P W <br />r <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 Januar >March X\ <br />January ,2G <br />Quarter 2 - April ----------->June <br />- July------------>Septembdk�G�,, <br />` - tober--------->December <br />Send to: SAN JOAQUIN PUBLIC HEALTH SERVICES. <br />ENVIRONMENTAL HEALT* DIVISION �j• �% yF <br />1601 E. Hazelton Ave., P.O. Box 2009 � <br />Stockton, CA 9y20i <br />(209) 468-3420 <br />