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PW *NVENTORY. RECONCILIATION qo RECEIVED <br /> QUARTERLY SUMMARY REPORT FORM <br /> 4UL 2 19C <br /> Facility Name: 4 Tank # _Pro Puct <br /> Facility Address: <br /> y(t, <br /> C Ic 13 11 W <br /> Telephone: sl'-Z <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. (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. (Les in Column 13 of the Inventory Reconciliation <br /> Sheet) . <br /> List date, tank f, amount for all variations and the reason <br /> for exceeding the allowable limits. <br /> Qate Tank Amount Reason <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 /> It 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 /> ----------->June <br /> Quarter 3 July ------------>September'-' <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 <br /> Stockton, CA 95201 <br /> (209) 468-3420 <br />