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INVENTORY RECONCILIATION OCT 01 9987 <br /> QUARTERLY SUMMARY REPORT FORM ENVIROMENTAL HEALTH <br /> FERMIT/SERVICES <br /> Facility Name: j /� j�leT,, 1,��' y,, Sank i Size Product <br /> Facility<Address: �j 1 - <br /> z2- ,.< <br /> Telephone : <br /> Person Filing / <br /> Report qc3 <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 /> E] Inventory 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) reles' se. (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 Sank ! Amount <br /> 1. <br /> 2. <br /> 3. <br /> 4. <br /> 5. <br /> Additional dates/amounts shall be continued on a separate sheet of <br /> paper .and attached. <br /> If the source of the variation uhich. exceeded allowable limits was due to <br /> a leak the incident shall be reported to S .J .L.H . D. Environmental Health <br /> within 24 hours and an unauthorized release report submitted. <br /> The quarterly summary report shall be xubmitted within 15 days of the end of each <br /> quarter. <br /> Quarter I - January --) March <br /> Quarter 2 - April --> Junc <br /> Quarter ) - July <br /> Quarter 4 - October --) December <br /> Send to: SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E . Hazelt4ln . P .O. 1124a._2009 <br /> Stockton . CA 95201 466 -6761 <br /> UGT 40 IO/ 86 <br />