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wv <br />INVENTORY RECONCILIATIO0 <br />r .' M• APR 1 6 <br />QUARTERLY SUMMARY REPORT FO <br />. RIfyt��C��'�pME,'•,,`'�.I_ ; _ <br />y Name • �.-�2CG ( n� \f k- Tank Proctu <br />Facility <br />� <br />� FacilityAddress: UO <br />U <br />Telephone: a 3 - 'Lois ppF�e,� y <br />Person Fil-Irla` <br />Report: <br />I � <br />\I -- <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 <br />1. <br />2. <br />3. <br />4. <br />5. <br />Tank <br />Amount <br />Reason <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 />1 - <br />The quarterly summary report shall be submitted within fifteen (15) days of <br />the end of each quarter. Circle appropriate quarter. <br />January ---------- >March <br />Quarter 2 - Anri_ <br />Quarter 3 <br />Quarter 4 <br />I <br />- July ------------>September <br />October --------->December <br />Send to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION <br />�i�/S ��• S.sti ✓o,q�' �� - - P.O. Box 2009 <br />Stockton, CA 95201 <br />(209) 468-3420 <br />EH 23 019 (10/89) <br />