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1� <br />INVENTORY RECONCILIATION <br />QUA/RJTERLYr� SUMMARY REPORT FORM <br />Facility Name: li ��rGt1 /�4A)t l�//��10 ? / _ <br />Facility Address: IfillW h ) A) <br />Telephone: 173 3 -y3.2 7 <br />Person Filing <br />Report: <br />Tank # I Size i Product <br />. <br />J <br />EJ <br />I hereby certify under penalty of perjury that all inventory <br />variations for the above mentioned facility werewritjdt <br />allowable limits for this quarter. (No in column <br />E D <br />Inventory Reconciliation Sheet.) I� <br />Inventory variations exceeded the allowable limi s or Atli s 8 1992 <br />,I quarter. I hereby certify under penalty of y e AW QHAL HEALTH <br />source for the variation was not due to authorized ?W43/3ERViCES <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 <br />2. <br />3 . LC3 Y. 1 7 ) 9 <br />4. <br />5. <br />Amount <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 <br />- January <br />Quarter 2 <br />Quarter 3 <br />__------->March <br />- April ------->June <br />- July -11 --------- >September <br />Quarter 4 <br />- Octobers --------- >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 />