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INVENTORY i'1' <br />JUARTERLY SUMMARY PO, O+ <br />Facility : 4TATION <br />.. <br />Ss #Ia-992 <br />Facility Address: 1202 W.H <br />7770-717,17. 777; 7-91M <br />Telephone: <br />Person Filing <br />Report <br />-Y - <br />®r AI <br />U I hereby certify under penalty of perjury that all inventory variations for <br />abovethe ,, <br />quarter. (No in Column 13of the Inventory Reconciliation Sheet) <br />Inventory 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) releise. (Yes in Col 13 of the <br />Inventory Reconciliation Sheet) <br />List date, tank I# and amount for all variations that exceeded the <br />allowable limits. <br />Date Tank Amount <br />1. <br />2. <br />3. <br />4. <br />5. <br />Additional dates/amouats shall be continued on a separate sheet of <br />paper an® 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 />Q►1 -2., - April --> June <br />arter 3 July --> September <br />Quarter 4 - October --> December <br />Send to: SAN JOAQUIN LOCAL HEALTH DISTRICT <br />1601 E. Hazelton. 11.0. Box 2009 <br />Stockton, CA 95201 466-6761 <br />UCT 40 10/86 <br />