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•INVENTORY RECONCILIATION <br />QUARTERLY SUMMARY REPORT FO <br />Facility Name: h Oak) UI %LL&T) LL <br />Facility Address: of <br />Telephone : a 0 l� - y 7 2,- -7:3',3'7 <br />Person Fillnu��-� <br />Report: n <br />9 RECEIVES <br />JUN 17 1992 <br />� ENVIRONMENTAL HEALTH <br />0 I hereby certify 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 />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 Tank Amount <br />92 <br />elm - <br />2. -a7- 9a 1i` r <br />3 . .� ! f��w -�) - X29 - s _ - & --?'a � 3 ,,?o ?;Z � <br />5. <br />Reason <br />-/j-lam( <br />I %27 -92 <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 />Quarter 1 - January -__------->March <br />Quarter 2 - April ------->June <br />Quarter 3 - July -1? --------- >September <br />Quarter 4 - October'% --------- >December <br />Send to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION <br />1601 E. Hazelton Ave., P.O. Box 2009 <br />Stockton, CA 95201 <br />EH 23 019 (10/89) (209) 468-3420 <br />