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INVENTORY RECONCILIATION „ (1Q'] <br /> LyJ'J <br /> QUARTERLY SUMMARY REPORT FORM <br /> ENVik(,% E^:TAL HEALTH <br /> �p�d r2ao2 RIdl1T/SERVICES <br /> Facility Name: Tank / Size Product <br /> -7 oira d'vlG�d' <br /> Facility Address: 34,f�0 <br /> 71-77_7751- <br /> Telephone : t/i�s 76x6 <br /> Person Filing <br /> Report <br /> I hereby certify under penalty of perjury that all inventory variations for <br /> the above mentioned facility were within the allowable limits for this <br /> quarter. (No in Column I7of the inventory Reconciliation Sheet) <br /> inventory variations exceeded the allowable limits for thin quarter. I <br /> hereby certify under penalty of perjury that the source for the variation <br /> was not due to an unauthorized (leak) release. (Yes in Column 13 of the <br /> Inventory Reconciliation Sheet) <br /> List date, tank i, and amount for all variations that exceeded the <br /> allowable limits. <br /> Date Tank / Amount <br /> z. <br /> r-7 7 <br /> ]. 6- (0 / /Z- <br /> 4. <br /> Z4. 6- 26 / ;f< <br /> 5. 4-7 <br /> Additional dates/amounts shall be continued on a separate sheet of <br /> paper and attached. <br /> If the source of the variation which exceeded allowable limits was due to <br /> a leak the incident shall be reported to S .J . L. H . D . Environmental Ncalth <br /> within 24 hours and an unauthorized release report submitted. <br /> The quarterly summary report shall be submitted within 15 days of the end of each <br /> quarter. <br /> Quarter 1 - January --> March <br /> Q,Aarter 2 - April --> June <br /> Quarter 7 - July --> September <br /> Quarter 4 - October --> D1 comber <br /> Send co: SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 160 1 [--- . Haze 1 1 -ui , P .0 . lips 2()()9 <br /> Stockton . CA 95201 466 -67bl <br /> UI;T 40 10/ 86 <br />