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Facility <br />Facility <br />Telepho <br />Person <br />Report <br />INVENTORY RECONCILIATION <br />QUARTERLY SUMMARY REPORT FORM <br />� Sam <br />JAN 131983 <br />EN\JA FZom I SERV\GE9 TH <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 13 of the Inventory Reconciliation Sheet) <br />Iaventory variations exceeded the allowable limits for this Quarter. i <br />hereby certify under penalty of perjury that the source for the variation <br />was not due to an unauthorized (leak) rel"se. (Yes in Column 13 of the <br />Inventory Reconciliation Sheet) <br />Gist dater tank /, and amount for all variations that exceeded the <br />allowable limits. <br />Date G <br />4. <br />S. <br />Tank i Amount <br />Additional dates/amouats shall be continued on a separate sheet of <br />paper and attached. <br />It the source of the variation which exceeded allocable limits was due to <br />A leak the incident shall be reported to $.J.L.H.D. Environmental Health <br />Within 24 hours and an unauthorized release report submicted. <br />The Quarterly summary rrport shall be submi(ted within 15 days of the end of each <br />Quarter. <br />Quarter 1 - January --) March <br />QQaarter 1 - Apri l --> Junc <br />Quarter I - J.,1y --) ]ep(emher <br />Quarter 4 - October --) rk-cemther <br />Send to: SAN .JOAQUIN LOCAL HEALTH DISTRICT <br />1601 E. 0azt•1tun. 1'.0. 14oix 2009 <br />Si ockton. CA '15201, 460-61111 <br />IJCT 40 IO/Hb <br />