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INVENTORY RECONCILIATI I S Z <br /> UARTERLY SUMMARY REPORT <br /> . Facility Name: r�� �Rrc�il•4T �'. <br /> Tank Size I Product <br /> Facility Address: �Z1 X5 41 E + E ° coo E5� <br /> Telephone: Z 43 • Z1,;:1 �` <br /> Person Filing <br /> Report: s6i '1 S KQf I <br /> (� I hereby certify under penalty of perjury that all inventory <br /> �J 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 Lm� t <br /> Reason <br /> i. .AD <br />� <br /> 2 . 64- 1 +l u-1 <br /> 3 . OS-14-10 I�eAS;.; 1r sem• <br /> US�_—. + r+ <br /> Nle ann~ <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, Environmerital 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 /> 1 <br /> January---------->March <br /> oio Quarter - April ---------__ <br /> uar er 3 - Jul ------------->Sepe <br /> y >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 /> Stockton, CA 95201 <br /> EH 23 019 (10/89) (209) 468-3420 <br />