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INVENTORY RECONCILIATION APR 111989 <br /> QUARTERLY SUMMARY REPORT 'FORM Wy'If?01WIIENTALHEALTH <br /> PERK4 ITI SERV]r-'F" <br /> Facility Name' Tank Size Product <br /> Facility Address: <br /> 4,5n -, <br /> 4. <br /> 33 <br /> Telephone : c - <br /> Person Filing <br /> Report cJ Ac t roc.,.S <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 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) release. (Yes in Column 13 of the <br /> Inventory Reconciliation Sheet) <br /> List date, tank #, and amount for all variations chat exceeded the <br /> allowable limits. <br /> Date Tanis F Amount <br /> 1_ <br /> 2_ <br /> 3_ <br /> 4. <br /> S_ <br /> Additional dares/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 March <br /> Quarter 2 - April --> June <br /> Quarter 3 - July --) September <br /> Quarter 4 - October --> Chcember <br /> Send co: SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E , Faze l t_011 , P . 0 . 1�Ox 2()O9 <br /> Stockton , CA 95201 460 -0781 <br /> U(,T 40 LO/ 86 <br />