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INVENTORY RECONCILIATION <br />QUARTERLY SUMMARY REPORT FORM <br />Facility Name: <br />Facility Address: <br />Telephone: <br />Person Filing <br />Report: <br />I hereby certify under penalty of perjury that all inventory <br />10 variations for the above mentioned facility <br />allowable limits for this quarter. (No in <br />Inventory Reconciliation Sheet.) <br />El J U N 1 7 19931 <br />Inventory variations exceeded the allowabl <br />quarter. I hereby certify under penalty o� p ���T hisource for the variation was not due to autho;WJA <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 />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.alrowahle 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 tvienty-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------ <br />arter 2 - April ----------->June <br />Quarter ------ <br />ember <br />--Quarter 4 - October --------->December <br />Send to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION <br />1 P.O. Box 2009 <br />Stockton, CA 95201 <br />EH 23019 (209) 468-3420 <br />(10/89) <br />