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ONVENTORY RECONCILIATION <br />QUARTERLY SUMMARY REPORT FORM <br />0 <br />Facility Address: c�o'M o,5c- m, ­JE A ve <br />Aa±!F_CA,' Q14 '15334P <br />Telephone, <br />Person F ing <br />Report: H_r�AL <br />VISM 11 <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 1, amount for all variations and the reason <br />for exceeding the allowable limits. <br />Amgunt <br />Season <br />`7 <br />2. 0- ?'% <br />G7 ri�,s Lop'D <br />3. +r'-? <br />kc'tqn. <br />4. _3 <br />GLaL LLL, <br />5. i 10 <br />Iq S ko '�) I-) <br />Additional dates/amounts shall be continued on <br />a separate <br />sheet of paper and attached. <br />If the source of the variation which exceeded allowable <br />limits <br />was due to a leak, the incident shall be reported to <br />Public <br />Health Services of San Joaquin County Environmental <br />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 ------ ; ----- >March <br />Quarter 2 - April ----------- >June <br />Quarter 3 - July ------------ >September <br />Quarter 4 - October --------- >December <br />Send to: SAM JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION <br />1.601 E. Hazelton Ave., P.O. Box 2009 <br />Stockton, CA 95201 <br />(209) 468-3420 <br />EH 23 019 (10/89) <br />AWL <br />