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INVENTORY RECONCILIATION <br />. MARCH L I A%Y SUMMARY REPORT FORM <br />U 2701 W. MARCH LANE <br />Facility Name:-.--,uOCKIaN. CA 95219 <br />Facility Address: 209473.7337 19527167 <br />Telephoner <br />Person Filin— <br />Report: ►�'qG ti�1P <br />AUG 1 2 tn1 <br />ENVIRONMENTAL HEALTH <br />L-- Tank # i S itw I / errs► - <br />Q 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 />y ~y 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 Tank # Amount Reason <br />L 1. <br />0-1HA A�e <br />2. <br />3. <br />4. <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 - 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 />EH 23 019 (10/89) (209) 468-3420 <br />