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0 0 RECEIVED <br /> INVENTORY. RECONCILIATION J U N 2 4 1992 <br /> QUARTERLY SUMMARY REPORT FORM ENVIRONMENTAL HEALTH <br /> PAUL' P iMIT/S �X� <br /> Facility Name: 601 " 76 Tank Si <br /> Lodi, CA F:�_�a;:;-�.,. ;' ;�� 0715 ' W4, <br /> Facility Address: Agri A,,b;Tk 2 S <br /> Telephone: i /I?r v7 <br /> Person Filing <br /> Report: <br /> i <br /> I hereby certify under penalty of perjury that all inventory <br /> L <br /> itions for the above mentioned facility were within the <br /> ble limits for this quarter. (No in column 13 of the <br /> try Rec-nnni l i a i an Sh A ) <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 i, amount for all variations and the reason <br /> for exceeding the allowable limits. <br /> Date Tank Amount Reason <br /> 1. <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 <br /> ubmitted.The quarterly summary report shall be submitted within fifteen (15) days of <br /> the end of each quarter. Circle appropriate quarter. <br /> ---------->March <br /> Qu t - ------->June <br /> Quarter 3 - July ------------>Sep em _Zr <br /> Quarter 4 - October --------->December <br /> Send to: SAN JOAQUIN 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 />