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ON <br /> 11r) <br /> INVENTORY. RECONCILIATION <br /> QUARTERLY SUMMARY REPORT FORM <br /> Facility Name: � � _ Tank size Product <br /> • aGC� L <br /> Facility Address: ,1 <br /> 2.Q4 GC]© C <br /> Telephone: Z/ � LII Q j,o- <br /> Person Fili i <br /> Report: i <br /> F <br /> I hereby certify under penalty of perjury tha <br /> variations for the above mentioned facility w <br /> allowable limits for this quarter. (No in col RWhe . <br /> Inventory Reconciliation Sheet. ) ,SAN 10 1592 <br /> Inventory variations exceeded the allowable i-NW*F W g p <br /> quarter. I hereb certif under penalty of per� �� <br /> 4 Y Y P Y <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 nk Amount Reason <br /> 1. <br /> 2 . <br /> 3 . <br /> 4 . 1 <br /> 5. <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 <br /> ubmitted.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 /> Quarter 3 - Jul ------------>Se tember <br /> uarter 4 - October --------->December ' <br /> Send to: SAN JOAQUIN PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 1.601 E. Hazelton Ave. , P.O. Box 2009 <br /> Stockton, CA 95201 <br /> (2 09) 468-3420 <br />