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Facility Name: <br />Facility Address:-� <br />L• iLZIAL-163 I'm <br />WN <br />1W INVENTORY RECONCILIATA <br />QUARTERLY SUMMARY REPORT FORM <br />I hereby certify under penalty of perjury tha , :411 in , vento , r <br />variations for the above mentioned facilit Ld" <br />allowable limits for thisquarter. (No in-columrgK3 W ja: <br />-.--inventory Reconciliation Sheet.) <br />ENVIRONMENTAL HEALTH <br />Inventory variations exceeded the allowable liRfJWIJ6gUJ�S <br />quarter. I hereby certify under penalty of perjury that the <br />source for the variation was not due to authorized (leak) <br />release. U—es in Column 13 of the Inventory Reconciliation <br />Sheet). <br />�u <br />List date, tank #1 amount for all variations and the reason <br />for exceeding the allowable limits. <br />A-mogilt- <br />• <br />tW,5 4, <br />2 • V, <br />17 <br />'y' 7' <br />0 <br />14 797 4?1 <br />717-077777-77--a --y- 1�0!r <br />'7–e <br />-aA a/7 3/0 <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 />ilKI) O - 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, ---),q q <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 />