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INVENTORY RECONCILIATI <br /> QUARTERLY SUMMARY REPORT �M <br /> Facility Name: <br /> Tan Size Product <br /> 1 ko CIs C <br /> Facility Address: Zgz7 oS tTE M <br /> Telephone: ZC <br /> Person Filing <br /> Report: N\ Ka <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 /> List date, tank #, amount for all variations and the reason <br /> for exceeding the allowable limits. <br /> Date Tank # .amount Reason <br /> - 9-3 <br /> 2 . Dl ' DJ ,` + 22-s <br /> 3 . <br /> MeAS4JREKWQ LJ! <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 /> $9 Quarter 1 - January---------->March <br /> uar er 2 - April -----------;,June <br /> Quarter 3 - July --------- >September <br /> Quarter 4 - October --------->December <br /> Send to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P.O. Box 2009 <br /> Q 111 V i LTi�1LG.L L+... <br /> !/T Stockton, CA 95201 <br /> (209) 468-3420 <br /> EH 23 019 (10/89) <br />