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✓� GNITORING ALTERNATIVE ifs <br /> y Inventory Reconciliation <br /> Quarterly Summary Report Form <br /> Tank# Size Product <br /> r, off' <br /> Facility Name: � 4 <br /> Fac' 'ty Address: b�� AX /�'/a71%! S <br /> a01 <br /> Telephone: <br /> Person Filing Deport: le �D <br /> I hereby certify under penalty of perjuryy that all inventory variations for the <br /> above mentioned facilitywere within t11e allowable limits for this quarter. <br /> (NO in column 13 of the Inventory Reconciliation Sheet.) <br /> Inventory variations exceeded the allowable limits for this quarter. I hereby <br /> fl certify under penalty of perjury that the source for the variation was not due <br /> to unauthorized (leak) release. (YES in Column 13 of the Itiventory <br /> Reconciliation Sheet.) <br /> gCEIVEIJ <br /> List date, tank number, and amount for all variations that exceede j 1 6 �4°� <br /> allowable limits. <br /> �f�iV RONMENTAL HEALTH <br /> Date Tank# Amoun ,EWAIT/SERVICES <br /> 1. <br /> 2. <br /> 3. <br /> 4. <br /> 5. <br /> Additional dates/amounts shall be continued on a separate sheet of <br /> paper and attached. <br /> If the source of the variation which exceeded allowable limits was due to a leak, <br /> the incident shall be reported to San Joaquin County Public Health Services; <br /> F.nvironmentai Health Services, within twenty-four (24) hours and an <br /> unauthorized release report submitted. <br /> The quarterly summary report shall be submitted within fifteen (15) days of the end of <br /> each quarter. <br /> Quarter 1: January 0 March <br /> Quarter 2: April 0 June <br /> Quarter 3: July t September <br /> Quarter 4: October » December <br /> Send To: <br /> San Joaquin County Public Health Services <br /> Environmental Health Services <br /> Post Office Box 2009 <br /> Stockton, CA 95201 <br /> (209) 468-3420 <br /> FHS 23 019 10/86 <br />