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INVENTORY RECONCILIATION <br />QUARTERLY SUMMARY RFPORT FORM <br />Facility Name. <br />Facility Address; X35 S Yom- <br />Telephone: 9��'�'°=�� 951 b <br />Person F'li� SIS <br />Report <br />El <br />L! <br />I hereby certify under penalty of <br />the above mentioned Perjury were within <br />quarter. theaallowablecntory variations Eor. <br />(No to Column 13 of the Inventor limits <br />y Reconciliation Sheet) <br />r this <br />Inventory variations exceeded <br />hereby certifythe allowable limits <br />under penalty of � y that for this quarter. <br />was sot due to an unauthorized per'ur the source I <br />Inventory Reconciliation Sheet) ( leak) release. for the variation <br />�Y�s in Column 13 of the <br />List date, tank #, <br />allowable limiand amount for all variations <br />that exceeded the <br />ts. <br />Date Tank I <br />1. f2 30 Amount <br />3.So <br />2. <br />J. <br />4. —� <br />5. _ <br />Additional dates/amounts shall be continued on a separate sheet of <br />Paper and aCtached. <br />IE the source of the variation which.exceeded allowable limits was d <br />a leak the incident shall be reported to S.J.L.H.D. Environmental <br />due [o <br />24 hours and an unauthorized release _t nmcntal Hcal[h <br />repo._ submitted. <br />q'hearterly suu rY report shall be submitted vithin IS days ° f the end <br />quarterly <br />mv <br />OE each <br />Quarter 1 - January March <br />Quarter 2 - A ril <br />p --> Juni <br />Quarter 7 - Jul <br />Quarter 4 - OY --� Scr <br />October --> (k -cemccmbebcr <br />Send to: <br />SAN JOAQUIN LOCAL HEALTH DIS'1'RIC'I' <br />1601 I:. Haze 1 tern , P.O. Rox 2009 <br />40 10/fl6 Stockton, CA 95201 466-6781 <br />' <br />