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INVENTORY RECONCILIATION <br />QUARTERLY SUMMARY REPORT FORM <br />Facility Name: IS 1 IINGGAL 76 <br />Facility Addr�� 01 E. Kettleman Lane <br />Telephone:- ARD. <br />Person Filing 6 g b 7r� <br />Report: <br />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 />(� 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 ,if, amount for all variations and the reason <br />for exceeding the allowable limits. <br />Date Tank I Amount <br />1. <br />2. <br />3. <br />4. <br />5. <br />Reason <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-------- <br />ri 1-----------> June E C E I V E D <br />Y ------------ >September <br />Quarter 4- October --------->December J U N 2 6 1990 <br />Send to: SAN JOAQUIN COUNTY PUBLIC HEALTH sElift NMENTAL HEALTH <br />ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES <br />1601 E. Hazelton Ave., P.O. Box 2009 <br />Stockton, CA 95201 <br />(209) 468-3420 <br />EH 23 019 (10/89) <br />