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g <br /> INVENTORY, RECONCILIA*N <br /> ` QUARTERLY SUMMARY REPORT FORM <br /> Facility Name: _041,1p O ��=E <br /> d6v <br /> Facility Address: <br /> 6Ud <br /> 2057 S.E i <br /> Telephone: STOCKTON(209)465-8210 0���. <br /> Person Filing <br /> Report: <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. (NQ 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 1, amount for all variations and the reason <br /> for exceeding the allowable limits. <br /> ate Tank I Amount Reason <br /> co <br /> 3. <br /> 4. <br /> 5. <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 ----44J9�--->June 1194 <br /> Quarter 3 - July ------------>September <br /> Quarter 4 - October --------->December <br /> Send to: SAN JOAQUIN PUBLIC HEALTH SERVICES G <br /> ENVIRONMENTAL HEALTH DIVISION -110�tl <br /> '~1 <br /> 1601 E. Hazelton Ave. , P.O. Box 200"�'nn u` ,=�"V�" "'rel <br /> Stockton CA 95201 GAS a <br /> S (� 2057 ti, <br /> � 6- (209) 468-3420 STOCKTON(M`)455-8210 <br />