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%ENTORY RECONCILIATIO <br />•RLY SUMMARY REPORT <br />Facility Name:►c� <br />Facility Address. I) <br />Telephoner <br />Person Filing <br />Reports <br />67U CC <br />® <br />cc R <br />C <br />n- <br />® I'es e <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 />cele se. (Yes in Column 13 of the Inventory Reconciliation <br />m <br />�& List date, tank 1, amount for all variations and the reason <br />3 1 for exceeding the allowable limits. <br />rV_�hi�' .'w 4 I AL <br />CV1► �x.�e. Date <br />', fj�� j mou t Reason <br />1e U " 11 j <br />2. <br />. <br />5x_16 <br />_fLL Lo <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-----e----'March <br />Quarter 2 - April ----------->June <br />Quarter 3 - July ------------>September <br />Quarter 4 - October --------->December <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION <br />1601 E. Hazelton Ave., P.O. Box 2009 <br />Stockton, CA 95201 <br />(10/89) (209) 468-3420 <br />