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0 <br />INVENTORY RECOt1CIL1ATION <br />QUARTERLY SUMMARY REPORT FORM' <br />Facility Nate: �� �� �,►� <br />Fac. icy Addresa•� <br />Telephone : <br />Person Fil' <br />Report' <br />t. <br />l:J l hereby certify under penalty of perjury that all inventory <br />the above mentioned facility were within the al Lovable limitsVforathis <br />s For <br />q"arcer- (No in Column 13 of the lovencory Reconciliation Sheet) <br />Q Inventory variations exceeded the allowable Limits for thisua <br />hereby certify underpenaltyof 4 rtar. I <br />was not due to an unauthorized (leak)rrelease. (yes ineColumnfor h3 of eion <br />th <br />Inventory Reconciliation Sheet) —" e <br />List date, taak 1, and amount for ail variations that exceeded the <br />allowable limits. <br />Date Tank I Amount <br />2. <br />3.�r�, <br />4. <br />5. <br />Additional aheamou <br />Paper and Zccttached- <br />ots shall be continued on a separate sheet of <br />If the source of the variation which exceeded allowable limits was due to <br />a leak the incident shall be reported to S <br />within 24 . J . L . H . D . Environmental fica.l th <br />hours and an unauthorized rrlease report submitted. <br />The quarccrly summary report shall be .ubmi[tcd within IS Jays cit the t`nc! of <br />quarcr.r, <br />Quarter I - January --1 Harch <br />¢aarcer 2 April --> June <br />Quarter 3 - July --> September <br />Q"arter 4 - October <br />Send to: SAN JOAQUIN LOCAL HEALTH DISTRIC1' <br />1601 E. Hazelton, P.O. Box 2009 <br />LICT 40 10/86 Stockton, CA 95201 466-6781 <br />