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! • P <br /> INVENTORY RECONCILIATION <br /> QUARTERLY S MMARY REPORT FORM JU 15198 <br /> 16-31 <br /> NWONMENTAL HEALTH <br /> Facility N=e: )-C ��T, '} = :��r�' rank # Size ct <br /> Facility,'Address: G <br /> Telephone : 2,9 a LL ,- <br /> Person Filing , <br /> Report `, =7ZIZ2Z[.a 't <br /> ®'T 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. (%amu' in Column 13of the inventory Reconciliation Sheet) <br /> QInventory 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) releise, (Yes in Column 13 of the <br /> Inventory Reconciliation Sheet) <br /> List date, tank 0, and amount for all variations that exceeded the <br /> allowable limits_ <br /> Date Tank f Amount <br /> 1. <br /> 2. <br /> 3_ <br /> 4. <br /> S. <br /> Additional dates/amouats shall be continued on a separate sheet of <br /> paper and attached. <br /> If the source of the variation which. exceeded al-lovable limits was due to <br /> a leak the incident shallbe reported to 5 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 /> Q+1arter 2 - Aprit --) June <br /> Quarter 3 - .July --) September <br /> Q+jartcr 4 - October --) fkcember <br /> Send co: SAN JOAQUIN LOCAL HEALTH DISTRICT" <br /> 160L E . HaZe l l fill , P .O . liox 2009 <br /> SLockeon , (:A 95201 466-6781 <br /> uc;�' 4() 10/ 86 <br />