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�'-- <br />INVENTORY RECONCILIATION <br />QUARTERLY SUMMARY REPORT FORM <br />Facility Name:N o Is <br />�C �Vi�..a <br />Facility Address: Ivo 19roroozx-1,� <br />7 GE,, C.4, <br />Teleph e: <br />Person 'ng <br />Repor 4 .G1, <br />ma ntr 4 <br />7/91q o <br />1 1 VlA4V {.� <br />a <br />3 0 e.) o o� <br />(`r I hereby certify under penalty of perjury tha <br />�.-.J variations for the above mentioned facility wREOVID. <br />allowable limits for this quarter. (No in columdn3 1c*f 1 <br />Inventory Reconciliation Sheet.) ENVIRONMENTAL HEALTH <br />Inventory variations exceeded the allowable lJ?L8&4IT&V%J&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. (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• G <br />4. <br />Tank <br />I <br />2 <br />Amount <br />�o <br />/73 <br />:;4 o <br />3 m �. <br />Reason <br />Eat-aQ- <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 />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 �Y <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 <br />'.4 <br />