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I <br />r` <br />y ' <br />INVENTORY RECONCILIATION <br />QUARTERLY SUMMARY REPORT FORM <br />Facility Name: Tank Size Product <br />`-� Facility Address: �—m kejhe'"""'� <br />Telephone: SLFJ S 77 WD <br />Person Filing 071 <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,,#, 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 />�s <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,al2owaple limits <br />was due to a leak, the incident shall„,be reported to Public <br />Health Services of San Joaquin County.Environmertal Health <br />Division, within twenty-four (24) hours and an unauthorized <br />release report submitted. <br />The quarterly summary report shall be submitted withan fifteen (15) days oft <br />the end of each quarter. Circle appropriate quarter. <br />Quarter ,- <br />Q -- .� a�,�arv------- >March <br />Quarter 2 - pri -- ->June <br />Quarter 3 - July ------------>September <br />Quarter 4 - October --------->December <br />RECEIVE'D' <br />Send to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISIONY <br />1601 E. Hazelton Ave., P.O. Box 2009 A <br />ENVIRONMENTAL E LT <br />Stockton, CA 95201 <br />EH 23 019 (209) 468-3420 IT/ ICES <br />(10/89) <br />