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Facility Name: <br />� Facility <br />0.- • <br />INVENTORY RECONCILIATION <br />QUARTERLY SUMMARY REPORT FORM <br />MARCH LANE UNION 76 <br />2701 W_ MARCH. LANE L Tank # I_ <br />STOCKTON,CA 95219 1 <br />Address: 209-473-7337 <br />Telephone: <br />Person Filin <br />Report: _%�Z <br />rvu3� <br />o I hereby certify under penalty of perjury t <br />444 al ✓�-o�y <br />variations for the above mentioned facility 4r a VitlAn theme <br />allowable limits for this quarter. (No in coluNT14 pt he <br />Inventory Reconciliation Sheet.) <br />r, r , <br />Ed Inventory variations exceeded the allowable 1As <br />iaaa3ts�,'Q <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 Reason <br />1. <br />1 <br />2. v k l( -,C �1 � `'� 1 ��1 <br />� 1 <br />4. <br />N <br />5. <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 - Januar__------->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 />