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INVENTORY RECONCILIATIOT� J U L 1 7 1201 <br /> QUARTERLY SUMMARY REPORT FORM ENVIRONMENTALHEALTH <br /> Facility Name: L"Sb,� C:xA�fjeTank PkRMIT/SERVICES <br /> 1. # i Size i Procjpct i <br /> Facility Address: 20 3 '2 'VI <br /> Telephone: - <br /> > <br /> Person Fili�g� _ <br /> Report: <br /> ( . I hereby certify under penalty of perjury that all inventory <br /> L/G_\ 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 /> l� 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 Tank Amount <br /> Reason <br /> 1. <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 t*aenty-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 <br /> Quarter 2 - Aoril -------- <br /> -__-- ->Ma ��ok <br /> 1 <br /> �Q� --_June <br /> arter 3 July - -->Septem er <br /> Quarter 4 - October --------->December A <br /> Send to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> -Al. Scti ^ P.O. Box 2009 <br /> � k,� Stockton, 95201 <br /> EH 23 019 (10/89) (209) 468-3420 <br />