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� INVENTORY RECONCILIATI <br /> UARTERLY SLAY REPORT 11,WRM <br /> Facility Name: � ki-mss <br /> Tan Size Product <br /> Facility Address: `Z�12 <br /> TiE <br /> Telephone: zn <br /> Person Fili, Z1 � — <br /> Report: IVI �ec� 2s 5�t X85_ ) <br /> ElI 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. Y 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 /> LnNy <br /> 3 .�1�� -`� a _ TL I�lx` <br /> cor.-,eefAE&n e <br /> 4. b zl- 9� i +1b5 <br /> '' Lo(. b�j Dep- <br /> 5. 09-o -90 <br /> 4161 <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 ----------->June <br /> O Quarter -!b July ------------>September <br /> carter 4 - October --------->December <br /> r 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) 458-3420 <br />