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INVENTORY RECONCILIATION* <br />UARTERLY SUMMARY REPORT FORM <br />Facility Name: '-UWVfFYGc-�1S <br />Facility Address:2�7 601AV7f_Ze_,LU' <br />ri C <br />Telephone:2-0- q4% d <br />Person FilinIUA� <br />S lerN rV Ri rrEw <br />Report: i ._ a, <br />�a <br />!�•��, O <br />I hereby cer-tliff 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 />y2eet). <br />c <br />W <br />"'(n List date, tank #, <br />Z; for exceeding the <br />O a: <br />?" Date <br />:J <br />amount for all variations and the reason <br />allowable limits. <br />Tank <br />/�. 1 2 . )1A, <br />3. <br />4 .Sf P7, S U <br />5.,54'e- P7 <br />Additional dates/amounts shall <br />sheet of paper and attached. <br />Amount <br />be continued <br />Reason <br />S71 &F -j <br />57/a J, <br />37/OU- <br />_57/ <br />7/OU-,S7/ 0- /' <br />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 - April ----------->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 />