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PE <br /> P.U. t$UA 33� <br /> FRENCHCAMPmQA H'TORT RECONCILIATION <br /> QUARTERLY SUMMARY REPORT fORM <br /> FacWty Name:�Z t� �� �,hl\ ' �'a Tank / Size Product <br /> rscility Address: <br /> Telephone : '0{R 27 <br /> Person Filing <br /> Report <br /> ❑ L hereby certify under penalty of perjury that all inventory variations for <br /> the above a.eaeioned facility .,ere within the allowable limits for this <br /> Quarter. (No in Column 13 of the Inventory Reconciliation Sheet) <br /> Loventory variations exceeded the allowable limits for this Quarter. I <br /> hereby certify under penalty of perjury that the source for the variation <br /> wan not due to as uoauthorised (leak) re Lease. (Yes in Coltman 13 of the <br /> Inventory Reconciliation Sheet) r <br /> Last date. tank /, and amount for all variations that exceeded the <br /> Allowable limits. <br /> Date Tank I Amount <br /> 1 <br /> 2. <br /> 3. <br /> 4. <br /> s. <br /> Mditioosl daces/amount, shall be continued on a separate sheet of <br /> paper and attached . <br /> If the source of Che variation -114th c,eecded allow ble limits vas due Co <br /> 4 '" the incident shall be reported to $ J 1. H . p Environmental Ilcalch <br /> . <br /> within 24 hours and an una,rthornccd release rcpor( submitted . <br /> ITe Quarterly ,.,y report shall be Kubmi <br /> Qu.rter CCcd vr(hrn IS days of the end of tach <br /> Quarter I - J.nuary <br /> Quarter ) - July <br /> Q'•artcr G - October --) Dr crmbcr g�- <br /> Send co: SAN JOAQUIN LOCA1. HEALTH DISTRICT <br /> 1601 E . I:ar.t• Ilrut , 1' . 0 Ro.e %009 <br /> L11;1 r,0 10/M6 Stockton , CA 95201 466 -6761 <br /> ' �.. <br />