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INVENTORY RECONCIZ. IATi0ti <br /> QUARTERLY SUMMARY REPORT FORM <br /> FaciLity Haeme: (1kA Ct1G4 t r �- c1 Tank r,t i[AL� H <br /> f f 7,U v Size 1 iv S4z, 'CES <br /> Facility Addre■s: U. L>6 <br /> A <br /> Telephone : o <br /> Person Filing <br /> Report ��ortJr�T. 4414 js' <br /> L hereby certify under penaltyo€ <br /> the above Perjury that all inventory variations for <br /> rationed facility were within the allowable limits for this <br /> quarter. (Ko in Column 13 of the. Inventory Reconciliation Sheet) <br /> ElInventory variations exceeded the allovable. 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) release. (Yes in Column 13 of the <br /> Iaventory Reconciliation Sheet) `- <br /> List date, tank !, sad aruount for all variations that exceeded the <br /> allowable limits. <br /> Date Wank E Amount <br /> 1. . <br /> 4. --- <br /> Additional dates/amounts shall be continued on a separate sheet of <br /> PaPer and attached. <br /> If the <br /> source of the variation which- etcecded allowable limits was due to <br /> A leak the incident shall. be reporter! Co S -.J .L.H . b- Environmental health <br /> within 24 hours and an unau[horized release report submi[tcd. <br /> The quarterly summary re"rt shall be aubmitCed within 15 days of the end of each <br /> quarter. <br /> Quarter I - January --� March <br /> Q'iarter 2 - April --> June <br /> Quarter 3 - July __) yeptemhc:r <br /> Quactcr4+ _ October _-) f}c.ccmbGr <br /> Send to: SAN JOAQUIN LOCAL HEALTH DISTRICT' <br /> 1601 1'.. HaZCIL(m . P .O . lto .x <br /> r,() 1(1/f3 6 Stockton , CA 95201 466-6781 <br /> � <br />