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OCT F, <br /> I<NVwRQ.0ENIAL HEALTH <br /> INVENTORY RECONCILIATION FERMIT/SERVICES <br /> QUARTERLY SUMMARY REPORT FORM <br /> Facility Name' G'C <br /> Tankf Size Product <br /> Facility Address: ' e , 19,0y' 7 <br /> Lu ( `533 6 4e �ddr <br /> Telephone : - 7 <br /> Person Fillg <br /> Report 'J6, 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. (No in Column 13 of 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) release. (Yes in Colum 13 of the <br /> Inventory Reconciliation Sheet) <br /> List date, tank 1, and amount for all variations that exceeded the <br /> allowable limits. <br /> Date Tank I Amount <br /> i. <br /> 2. <br /> 3. <br /> 4. <br /> 5. <br /> Additional dates/amounts shall be continued on a separate sheet of <br /> raper and attached. <br /> If the source of the variation whichexceeded 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 /> Qua <br /> Quarter 4 - October ---> I}ccember <br /> Send to: SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1.601 E . Haze 9 toll , P .O . Box 2()()9 <br /> Stockton , CA 95201 466 -6781 <br /> UGT 40 10/86 <br />