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INVENTORY, kECONCILIATI <br />QUARTERLY SUMMARY REPORT FORM <br />Facility Name: 0A1)1'/ will-, '`)n!�4 <br />Facility Address: _ I110 y UJ � rl-I'rt"tt <br />Telephone: <br />Person Filing , A <br />Report: I.vy" Ni UP c�Lh, <br />.�L 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. (Ho in column 13 of the <br />Inventory Reconciliation Sheet.) <br />Inventory variations exceeded the allowable limits forthi}} <br />quarter. I hereby certify under penalty of perjury that trie <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 0, amount for all variations and the reason <br />for exceeding the allowable limits. <br />Date Tank Amount so <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 b5, submitteQ 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 />carter July ------------>September <br />ar er 4 - October--------->9ecember <br />Send to: SAN JOAQUIN PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION <br />1601 E. Hazelton Ave., P.O. Box 2009 <br />Stockton, CA 95,201 <br />(209) 468-3420 <br />