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PINVENUA rUM TORY RECONCILIATION` <br />ARTERLY SUMMARY REPORT FO <br />Facility Name:Tank # Edze Prgdmct <br />C <br />Facility AddresyS7 IS <br />Tele n e, <br />Person Filing. <br />Report: i <br />a4hereb ce and r penalty of perjury that all inventory <br />riations fo he above mentioned facility were within the <br />allowable limits for this quarter. (No in column 13 of the <br />Inventory Reconciliation Sheet.) <br />story 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 />Lis a e, an , amount for all variations and the reason <br />for exceeding the allowable limits. <br />Date <br />r Tan <br />1s <br />2.- 1 <br />3.1 <br />Wn <br />4. _ <br />5 . 1 LJ.Ju <br />aOLND <br />Ly U <br />Additional dates/amounts shall <br />sheet of paper <br />and attached. <br />0 <br />be continued on a separate <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 - Apri--------->June <br />Quarter 3 - July ------------>September <br />Quarter 4 - October --------->December <br />Send to: SAN JOAQUiN PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION <br />1601 E. Hazelton.Ave., P.O. Box 2009 <br />Stockton, CA 95201 <br />(209) 468-3420 <br />A 10 <br />SC, -C AP 0 '0 Cr -6? <br />R)" E <br />0_1 I rVA` <br />WOWTAIIrm <br />