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INVENTORY RECONCILIATION <br />QUARTERLY SUMMARY REPORT FORM <br />Facility NameLf ppr/) f�/t1 �C��U/0/L / (J i Tank # I Size i Product <br />Facility Address: G rd � N - r 1A, / E'! -c <br />7 777 C <br />Telephone: _ <br />Person Filing ✓y//�/1/11 ,(� <br />Report: ..................F ,� l �JC��✓� <br />El 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 />E D <br />Inventory variations exceeded the allowable lim i <br />t--,1 quarter. I hereby certify under penalty of perjuad!7e'al <br />8t�� <br />source for the variation was not due to authorizerelease. (Yes in Column 13 of the Inventory R �166HEALTH <br />Sheet) . PERMIT/SERVICES <br />List date, tank #, amount for all variations and the reason <br />for exceeding the allowable limits. <br />Date Tank Amount <br />2' <br />lS� J 51 l , �, :1 <br />3. <br />4. <br />5. <br />Reason <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'J--------- >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 />(209) 468-3420 <br />EH 23 019 (10/89) <br />