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INVENTORY RECONCILIATIO APR <br /> QUARTERLY SUMMARY REPORT FORM PIV '�(pN 19J� <br /> TAL HEALTH <br /> Facility tame: C (" ��/Orel/O`1%� /SERVICES <br /> / Tank I Site - P duct <br /> Facility Address: /6 7 /7'!5� <br /> Telephone : <br /> Person Filin <br /> Report <br /> ❑ L hereby certify under Penalty of perjury / <br /> P y P ] ry tha III Invento ' <br /> svforathis9 for.the above mentioned facility were within the allowable lim <br /> quarter. (Ho in Column 13 of the Inventory Reconciliation Sheet) <br /> VInventory 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 <br /> Inventory Reconciliation Sheet) in Column 13 of the <br /> List date, tank I, and amount for all variations that exceeded the <br /> allowable limits. <br /> Date Tank f <br /> Amount <br /> 2. <br /> 3. <br /> G. <br /> 5. <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 Ieak 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 --> December <br /> Send to: % SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. Hazelton , P .O . Box 2009 <br /> UCT 40 10/86 Stockton , CA 95201 466-6781 <br /> Janp, <br /> t P.P taw w LV 1�e <br />