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INVENTORY RECONCILIATION <br /> QUARTERLY SUMMARY REPORT FORM 4N � ' <br /> HEALTH <br /> Facility Name: /Djt �Y(TpJ /P(in. Tank I Size CES <br /> facility Address: �. jyJ # Z n <br /> _�73c.CTdrJ C/7 <br /> Telephone : gVa6 -:37/%- <br /> Person Filing / <br /> Report <br /> 14 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 /> ElInventory 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) rele'ase. (Yes in Colu® 13 of the <br /> Inventory Reconciliation Sheet) <br /> List dater 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 /> Additional dates/amounts shall be continued on a separate sheet of _ <br /> paper and attached. <br /> If the source of the variation whichexceeded 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 submitted within 15 days of the end of each <br /> quarter. <br /> Quarter I - January --) March <br /> Quarter 2 - April --> Juno <br /> Quarter 3 - July --> Septcmhcr <br /> a r ter 4 - oc tober -- •ccmber <br /> Send to: SAN JOAQUIN LOCAL HEALTH UISTH1CI' <br /> 1601 E. 11azellnn , P .O. flax.-.1009 <br /> Stockton . CA 95201 466 -67bl <br /> UCT 40 lO/H6 <br />