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0INVENTORY. RECONCILIATIOO <br /> QUARTERLY SUMMARY REPORT FORM <br /> Facility Name: Tank I size" . Product <br /> Facility Address: 11,000 14 <br /> Telephone: GAS AND G <br /> W-Wof 0.ftL DO <br /> Person Filing STOCKTON(209 4DO <br /> Report: <br /> as-e210 <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. (LIQ ie 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 #`, amount for all variations and the reason <br /> for exceeding the allowable limits. <br /> Date Tank I Amount Reason <br /> 1. <br /> 2. <br /> 3. <br /> M C=1_ <br /> 4 . <br /> _ VE <br /> 5. <br /> JAN 10 1992 <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 <br /> ,,/Quarter 3 - July ------------>September <br /> uarter 4 - October -497--++--->December �Jj( <br /> Send to: SAN JOAQUIN PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION ,( <br /> P.O. Box 200 u14cJVcSave 4 <br /> S N „�-3�11U,v$tockton, CA 95201 GAS AND GROCERY ���I �Z- <br /> (2 0 9) 468-3420 2057 S.EL DORADO <br /> 8TOCKTON(209)465-8210 <br />