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INVENTORY RECONCILIATION <br /> QUARTERLY SUMMARY REPORT FORM 2 <br /> VIRTA� HEALTH <br /> ( L <br /> Facility Name: Tank f Size OER 7 jy6auct <br /> Facilit Address: I IG C <br /> Y X00 E u'�� I� Ic. Dom <br /> Telephone : <br /> Person Filing <br /> Report CLO,cl�� 5.- <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 /> 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 f, and amount for all variations that exceeded the <br /> allowable limits. <br /> Date Tank rl Amount <br /> I. <br /> 2. <br /> 3. <br /> 4. <br /> S. <br /> Additional date=/a=uats shall be continued on a separate sheet of <br /> paper and attached. <br /> If the source of the variation which. erceeded 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 /> -r Q'iartcr 2 - April --> June <br /> Quarter 3 - July --> septemher <br /> Quarter 4 - October --> I1ccember <br /> Send to: SAN JOAQU Iry LOCAL HEAl-TH UISTH (Cr <br /> 160L l: . Haze 1 I ()n , P . 0 . lacy 2009 <br /> Stockton , CA 95201 1+66-6781 <br /> UI;T 40 10/ 86 <br />