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INYENTORY RECONCILIATION <br />�nUARTERLY SUMMARY REPORT FORM <br />Facility Namct <br />Facility Address: yea o <br />Telephone: <br />Person Fili <br />Report <br />u <br />APR 9 3 1 "1 <br />. ikONN Cr, AL HE, _ <br />F E RiVII 1TiSCERVI" <br />1 hereby ccrcify under penalty of perjury chic all inventory variations for <br />the above a ncioned facility were within the allowable limits for this <br />quarter. (No in Colusm 13 of the Inventory Reconciliation Sheet) <br />ElInventory variations exceeded the allowable limits for this quarter. I <br />hereby ccrCify under penalty of perjury that Che source for Che variacion <br />was not due to An unauchorized (leak) re Lease. (Yes in Column 13 of the <br />Iaventory Reconciliation Sheec) <br />List dater tank 1, and �nC for 21L variations Chic exceeded the <br />allowable limits. <br />Date Tank # Amouac <br />AddieionaL daces/amouots chall be cont-ioued on a separate +hecC 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 Co S.J.L,H.D. Environmental Healch <br />within 24 hours and an unauchorized release report submitted. <br />The Quarterly suaamry report shall be cubmitced within 15 days of the end Of "c" <br />Qu+icer. <br />Quarter I - Jaouery --) M.�rfh9Q <br />QQaartcr 2 - April <br />QuirCcr I - Jwly -_) .lc pCCmbcr <br />Q..areer i - October --> " cemLer <br />Send to: SAN JOAQUIN LOCAL HEALTH UI:;'""C' <br />i001 E. Haze l l "m . P .O . Kox 2..009 <br />SLOCkCMI. CA '15201 466-61bl <br />.0 In/N6 <br />