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Facility Name: t! <br />Facility Address: <br />10 <br />INVENTORY RECONCILIATI' <br />QUARTERLY SUMMARY REPORT't'v <br />kea <br />I hereby certify under penalty of perjury that ep, <br />. pry <br />variations for the above mentioned facility wer�Uhjmthe <br />allowable limits for this'quarter. (No in E9AfJWhrvW�-1dj Uii.Tl-i <br />Inventory Reconciliation Sheet.) PERMIT/SERVIGES <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 />F <br />A -mount <br />Additionar dates/amounts shall be continued on a separa <br />sheet of paper and attached. I <br />V <br />If the source of the variation which ex , ceeded 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 tiWenty-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 />Send to: <br />EH 23 019 <br />Quarter 1 - January ---------- >March <br />Quarter 2 - April ----------- >June <br />Quarter 3 - July ------------ >September <br />Quarter 4 - October --------- >December.- 'pq qo <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION <br />1601 E. Hazelton Ave., P.O. Box 2009 <br />Stockton, CA 95201 <br />(10/89) (209) 468-3420 <br />