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4INVENTORY, RECONCILIAT,o,*ECEIVEiiLARTERLY <br /> SUMMARY REPORT FORM <br /> JUL 519g' <br /> ENVIRONM <br /> Facility Name: tiG(S.'ly .S[t1,L� c�Q !, /a�Cc' L H ALIiAoduct <br /> ave RVI <br /> Facility Address: GAS AND GROCERY et Wrigno <br /> Telephone: <br /> Person Filing j <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. (K2 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 #, amount for all variations and the reason <br /> for exceeding the allowable limits. <br /> Date Tank I Amount Reason <br /> 1. <br /> 2. / <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 <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 ------>June (0I <br /> Quarter 3 - July ------------>Septem er <br /> Quarter 4 - October --------->December C.lu�el��J1/�SavE #4 <br /> GAS AND GROCERY <br /> Send to: SAN JOAQUIN PUBLIC HEALTH SERVICES N)57 S.ELDORADO <br /> ENVIRONMENTAL HEALTH DIVISION }t "''7N(2W)46 W10 <br /> 1601 E. Hazelton Ave. , P.O. Box 2009 <br /> Stockton, CA 95201 <br /> (209) 468-3420 <br />