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0.- ... 0 <br />INVENTORY RECONCILIATION <br />QUARTERLY SUMMARY REPORT FORM <br />Facility Name • _�il^�h;�i A�JeL�/A!i�,rt1 �� i Tank # I <br />Facility Address: -4L i a) <br />Telephoner <br />Person Filing <br />Report: Gi,-e'� <br />Q <br />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 <br />variations exceeded the allowable limits <br />for this <br />quarter. <br />I hereby certify under penalty of <br />source for <br />release. <br />Sheet) . <br />the variation was not dueto aut MKS= <br />(Yes in Column 13 of the Inventory Re <br />JJHHIIVV <br />on <br />on <br />List date, tank #, amount for all varg ix IRON MENTAL HEA�eason <br />for exceeding the allowable limits. PaYStO <br />Date Tank <br />/3; lS , � L+-).$� <br />2.) } 7u — <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 - January __------->March <br />Quarter 2 - April ------->June <br />Quarter 3 - July -1? --------->September <br />Quarter 4 - October's--------- >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 />