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SAN JOAS.vTIN COUNTY PUBLIC HZALTH S;n'TICES <br /> -j 0,ONMINTAL HEALTH DiVISIOW • <br /> i <br /> ANNUAL IN VEENTORY RECONCILIATION SUMMARY R--PORT � <br /> California UST Regulations, Article 4, Section 264a,(,j)_ <br /> LTH <br /> lCh <br /> Facility Name \ ` <br /> Address S� ` L-ox\ Q�� City L ck\ <br /> All inventory variations for the above mentioned facility were <br /> \within allowable limits of Title 23 , California Code of Regu{.ations, <br /> Division 3 , Chapter 16, Section 2646, for the 12 month period from <br /> 19 to 19 <br /> ❑ Inventory variations in excess of thQ 'wits of Section <br /> 2646, occurred as listed below. <br /> DATE TANK # / PRODUCT AMOUNT (Gallons) <br /> I <br /> 14 <br /> Submit report within 15 days following the end of the last month of the <br /> 12-month period covered by the report. Report to be submitted to: <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P.O. BOX 2009 <br /> STOCXTON, CA 95201 <br /> I certify under penalty of perjury, that all variations (if any) <br /> exceeding allowable limits are indicated above (California Health & <br /> Safety Code, Section 25299) : <br /> \MA jSQaA; <br /> Facility Tank Operator/Owner Date <br /> EH 23 019 B-1-92 <br />