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INVENTORY. RECONCILIA* <br /> QUARTERLY SUMMARY REPORT FORM <br /> Facility Name: Tank I size Product <br /> Facility Address: C0 <br /> avE <br /> /1 <br /> Telephone: GROCERY ►ya O� <br /> Person Filing STOCKT6N(209)4"210 <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. (No 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 /> Date Tank mountReason <br /> N LiJLL <br /> C" _� 1. <br /> 2. <br /> ZOO <br /> C.4 <br /> CDMC , <br /> �UU& 4. <br /> Z 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 <br /> ubmitted: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 --� -Z-->June <br /> Quarter 3 - July ------------>September <br /> Quarter 4 - October --------->December <br /> Send to: SAN JOAQUIN PUBLIC HEALTH SERVICES <br /> 4 <br /> J J . <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 1601 F Ha7p 1 ,g ,,pryer. , p.0. Box 200 ki ,:VV<S-avt #4 <br /> �tockton, CA 95201 GAS AND GROCERY <br /> (209) 468-3420 2057 S.ELDORADO <br /> �( 4, STOCKTON(209)465-8210 <br />