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INVENTORY RECONCILIATIO. <br /> QUARTERLY SUMMARY REPORT FORM <br /> Facility Name; C //r/ n�aGS— <br /> Tank f Site product <br /> Facility Address; <br /> i rre S3sc <br /> Te lephone : l /%i -5-4,e6 - <br /> Person Filing <br /> R,eaorc C <br /> i <br /> I hereby certify under penalty of perjury �, <br /> the above mentioned facility were within the aallowableelimitsvfor this <br /> s for <br /> Quarter. (No in Column 13 of the Inventory Reconciliation Sheet) <br /> CInventory 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 ao unauthorized (leek) 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 / <br /> Amount <br /> 1. <br /> 2. <br /> 3. <br /> 4. <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 Irak the incident shall be reported to <br /> within 24 hours and an unauthorized $,J .L.H. D. Environmental Health <br /> release report submitted. <br /> The quarterly summary report shall be submitted within <br /> quarter_ IS days of the end of each <br /> Quarter I - January --) March <br /> Quarter 2 - April --> June <br /> Quarter-3 - July <br /> --> Sepccmbcr <br /> Qt.arter 4. - October --> December <br /> Send col SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. Hazelton , P .O . Box 2009 <br /> UCT 40 10/86 Stockton, CA 95201 466-6781 <br />