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Facility <br />Facility <br />Telepho <br />Person <br />Report <br />INVENTORY RECONCILIATION C,�J <br />QUARTERLY SUMMARY REPORT FORM <br />Tank i Size product <br />c r c <br />T� 1 t,,- c a <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. (Ho in Column 13of 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) release. (Yes in Column 13 of the <br />Inventory Reconciliation Sheet) <br />List date, tank #, and amount for all variations that exceeded the <br />allowable limits_ <br />Date Tank / Amount <br />1. <br />2. <br />3. <br />4. <br />5. <br />AP? <br />ENVIRONMENTAL HEALTH <br />PERMIT/SERVICES <br />Additional dates/amounts 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 />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 --i Harch J790 <br />Quarter 2 April —> June <br />Quarter 3 - July September <br />Quarter 4 - October --) December <br />Send to: SAN JOAQUIN LOCAL HEALTH DISTRICT <br />1601 E. Hazelton, P.O. Box 2009 <br />Stockton, CA 95201 466-6781 <br />UCT 40 10/86 <br />