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IWI ME II'ORY RECONCILL2TZON <br /> SUMP-ARY RSPORT FOI;ZTe <br /> Facility Name: j Tank # Sf ze Drn� tit +• <br /> Facility Address: I I -._...' <br /> r y I <br /> Tzlephone: <br /> Person riling <br /> Report: <br /> QI hereby certify under penalty, of perjury that all inventory <br /> variations for the above mentioned facility were within the <br /> allowable limits for this quater. ( , 0- in column 13 of the <br /> Inventory Reconciliation Sheet. ) <br /> inventory variations exceeded the allowable limits for this <br /> quarter. T_ 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 if, amount for all variations and the reason <br /> for exceeding the allowable limits. <br /> Oate Tank mount Reason <br /> 2 Y�s,�.Lt� Z� <br /> J <br /> 4 : <br /> 5. <br /> Additional dates/amounts shall be. continued on a seoa=ate <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 ly summa_ry report shall be submitted within fifteen (15) days of <br /> the end of each qua+*-ter. Circle appropriate quarter. <br /> Quarty---- <br /> er 1 - Januar - >March = . <br /> Quar tar 2 - April ------- ->�Tune - - <br /> Quarter 3 - July -- ->September " - - <br /> Quarter .4 - October - <br /> :rd <br /> to": SAN JOAQUIN COUNTY PUBLIC HMAMTH�SF_RVICES <br /> Z�VIRON2�.£.*�TAL HZAr.TH D2VISION - <br /> 1601 ... Hazelton Ave., P.O. Box 2009 <br /> _Stockton, CA 95201- <br /> (209) <br /> 5201(209) 468-3420 <br /> ZH 22 019 (10/89) - <br />