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AP'R 15 OF <br /> INVENTORY RECONCILIATION ENVIROMENTAL HEAL.T <br /> QUARTERLY SUMMARY REPORT FORM FEWIT/SERVICES <br /> Facility Name; Tank 0Size Product <br /> Facility Address: , <br /> 53 <br /> Telephone : LI 3_ 312,' <br /> Person Filing <br /> Report <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 /> ElInventory variations exceeded the allowable limits for thin quarter. t <br /> hereby certify under penalty of perjury that the source for the variation <br /> wan not due to an unauthorized (leak) release. (Yes in column 13 of the <br /> Inventory Reconciliation Sheet) <br /> List date, tank f, and amount for all variations that exceeded the <br /> allowable limits. <br /> Date Tank f Amount <br /> 2- <br /> 3. <br /> 4. <br /> 5. <br /> Additional dates/amountx shall be continued on a separate sheet of <br /> paper and attached. <br /> If the source of the variation which- exceeded allowable limits was due to <br /> s Leak the incident shall be reported to S .J , L_ H _ p Environmental Health <br /> wtithin 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 /> anter 1 - January --) March <br /> Q+Yarter 2 - April --> June <br /> Quarter 3 - July --> September <br /> Quarter 4 - October --> necember <br /> Send to: SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 160L F . k,aze l t()n , P .O . Box 2009 <br /> Stockton , CA 95201 466-6781 <br /> LJGT 40 10/ 86 <br />