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Facility Name: <br />AA <br />0 INVENTORY RECONCILIATI <br />QUARTERLY SUMMARY REPORT F <br />Facility Address: v <br />Telephone: <br />Person Fi ' g <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;:_ R.t e <br />source for the variation was not due to au °' ) <br />release. (Yes in Column 13 of the Inventory,- 1' <br />Sheet) . <br />List date, tank #, amount for allv Jason <br />for exceeding the allowable limits. /�> <br />Date nk Amount <br />1. <br />2. <br />3. <br />4. <br />5. <br />Reason <br />i <br />Additional dates/amounts shall be continue 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 ---------- >March <br />Quarter 2 - April ----------->June <br />Qur___3 July ------------>September <br />Quarter 4 October === = === Ar <br />Send to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />_ENVIRONMENTAL HEALTH DIVISION <br />yys_ Al. S.i. ,l'� Ave., P.O. Box 2009 <br />Stockton, CA 95201 <br />(209) 468-3420 <br />EH 23 019 (10/89) <br />