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0 <br />y{k <br />Facility <br />W JIF411-111J, I I I <br />1Lxa72:(0UMV4f L UO <br />MWVWAKREM <br />size Product <br />i'iereby certilf� 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. I hereby certify under penalty of perjury that the <br />source for the variation was not due to authorized (leak) <br />lease. (Yes in Column 13 of the Inventory Reconciliation <br />eet). <br />C1QV <br />ist date, tank #, amount for all variations and the reason <br />or exceeding the allowable limits. <br />� 4to, <br />Ck, <br />I <br />Date <br />1.0(,-f- 1w <br />2.0,� IN <br />3.My ;L41N <br />4.MV A <br />5.t1h_ <br />® 0 E (-, ZZ -f <br />Tan li Amount Reason <br />I <br />4-W <br />4-)1/ <br />4-11 & <br />M <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 />Send to: <br />Quarter 1 - January ---------- >March <br />Quarter 2 - April ----------- >June <br />Quarter 3 - July ------------ >September <br />Quarter 4 - October --------- >December <br />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 />