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INVENTORY RECONCILIATION <br />QUARTERLY SUMMARY REPORT FORM <br />Facility Name: d J <br />r\� _ <br />FaciLicy Wdress: <br />Telephone: <br />Person Filing <br />Report <br />W : .. <br />I hereby certify under Penalty of <br />the above mentioned facility were withinytheaalLowablet all elimiCavforathias for <br />quarter. (Ko is Colu+mR ! t ca _ <br />the ',"vz"tory Reconci"Rtion 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 as unauthorized (leak) release. (Yes in Column 13 of the <br />Inventory Reconciliation Sheet) <br />List date, tank 1, and amount for all variations that exceeded the <br />allowable limits. <br />Date TA F Amount " L <br />1.2 . <br />ypgaav, <br />----------1-,Ag •; 1-, <br />J. <br />J�� <br />4. ENVIROMENTAL HEALTH <br />F ERM IT/SERVICES <br />S. <br />Additional dates/:mounts shall be continued on a separate sheet of <br />Paper and attached. <br />IE 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. Eavironmental Wealth <br />within 24 hours and an unauthorized 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 --> septembr.r <br />Quarter 4 - October --) Orcember <br />Send to: SAN JOAQUIN LOCAL HEALTH UISTRIC-1- <br />1601 E. Ilaze I t rill , <br />��0 lO/RG Stockton, CA X15201 466-67b1 <br />T <br />