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SAN JOAQSaL,4 COUNTY PUBLIC HEALTH SER CES <br />E NMENTAL HEALTH DIVISION <br />ANNUAL INVENTORY RECONCILIATION SUMMARY REPORT <br />California UST Regulations, Article 4, Section 2646tj)° <br />FALT , <br />Facility Name <br />Address <br />City Q t' �c <br />All inventory variations for the above mentioned facility were <br />ithin allowable limits of Title 23, California Code of ReguL-4.tions, <br />Division 3, Chapter 16, Section 2646, for the 12 month period from <br />19 to 19 <br />aInventory variations in excess of the allowable limits of Section <br />2646, occurred as listed below. <br />DATE I TANK # / PRODUCT I AMOUNT (Gallons) <br />Submit report within 15 days following the end of the last month of the <br />12 -month period covered by the report. Report to be submitted to: <br />SAN ZTOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION <br />P.O. BOX 2009 <br />STOCXTON, CA 95201 <br />I certify under penalty of perjury, that all variations (if any) <br />exceeding allowable limits are indicated above (California Health & <br />Safety Code, Section 25299): <br />)L,Ny\\C- n�\A <br />Facility Tank Operator/Owner Date <br />EH 23 019 8-1-92 <br />