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Facility Name: <br />Facility Addrect-,� <br />Telepho�@: d? <br />PersoT FiiNm7a <br />INVENTORY RECONCILIAT41 <br />DUARTERLY SUMMARY REPORT FORM <br />rj) <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. (Ko- in column 13 of the <br />entory Reconciliation Sheet.) <br />Inventory nventory 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 f, amount for all variations and the reason <br />for exceeding the allowable limits. <br />Qa <br />F/�— to Taak-z Amgunt- <br />10S <br />VI -7 <br />4fO <br />- 66 <br />-Additional:dates/amounts shall be continued on a separat 0 <br />sheet of paper and attached. I <br />0 <br />If the source of the variation which exceeded allowable limit <br />was due to a leak, the incident shall be reported to Public s <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 />Quarter 3 - July ------------ >September <br />Quarter 4 - October --------- >December <br />Send to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION <br />1601 E. Hazelton Ave., P.O. Box 2009 <br />Stockton, CA 95201 <br />EH 23 019 (10/89) (209) 468-3420 AMU <br />