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0 <br />INVENTORY RECONCILIATION <br />QUARTERLY SUMMARY REPORT FORM <br />;-o- ?C: � LANE UNION 76 <br />Facility Name: ,.7.�i--i'� MAPrN ANE <br />S70CKTON, CA 95219 <br />Facility Address: 73-7337 <br />-� <br />19527167 <br />Telephone: ?� ` r S 77 <br />Person Filin <br />Report: (i ue i1 s, <br />LA <br />AUG 12 1991 <br />I hereby certify under penalty of perjury that all inventory <br />ED 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 <br />1. 5 -S? -C-1 ( <br />2. ��1 <br />3. c� <br />4. <br />Tank <br />A <br />Additional dates/amounts shall <br />sheet of paper and attached. <br />Amount <br />Reason <br />be continued on a sp-parate <br />If the source of the variation which exceeded allowable limi-ts <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 -1f? ---------- >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 />(209) 468-3420 <br />EH 23 019 (10/89) <br />