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INVENTORY. RECONCILIAJBN <br /> QUARTERLY SUMMARY REPORTwFORN <br /> Facility Name: <br /> Product - <br /> 1 <br /> ell— <br /> Facility <br /> ^,l_ <br /> Facility Address: coca <br /> Telephone: u 4 ,' r <br /> Person Filin <br /> Report: _ i a 10,g i Z/ ma4? <br /> tg5 41 <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. (p2 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 1p amount for all variations and the reason <br /> for exceeding the allowable limits. <br /> Pate AmUT& ESA—Som <br /> 1. <br /> 2. <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 /> uarter 1' - January--J --> arch <br /> Quarter 2 - April ----------->June <br /> Quarter 3 - July ------------>Septemer <br /> Quarter 4 - October --------->December <br /> Send to: SAN JOAQUIN PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 1601_E. Hazelton Ave. , P.O. Box 2009-L '� , <br /> Stockton, CA 95201 <br /> Py��^ � (209) 468-3420 <br />