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INVENTORY RECONCILIATI� <br /> QUARTERLY SUMMARY REPORT FORM <br /> Facility Name: upyls-R- 2co-A - a4- Tank Size Product <br /> Facility Address: 1$000S•1-061A A. o <br /> P6B (U �` 0 0 "E <br /> o <br /> 952 D OD6 •00 iescl <br /> Telephone: (20c ) AR2_nslo <br /> Person Filinc <br /> Report: 7aK�.A�ry <br /> 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 /> REUE1VE' ast date, tank i, amount for all variations and the reason <br /> r exceeding the allowable limits. <br /> SEP 07132 <br /> ENViRONMEINTqL HFA fH Date Tank Amount Reason <br /> PER L . .. ., . ,:. _ a .2� au <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 fifteen (15) days of <br /> the end of each quarter. Circle appropriate quarter. <br /> Quarter 1 - January---------->March <br /> Quarter 2 - April ---------- une <br /> Quarter 3 - July ------------>September <br /> Quarter 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 95201 <br /> (209) 468-3420 <br />