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INVENTORY RECONCILIATION <br /> QUARTERLY SUMMARY REPORT FORMEN� 12 <br /> 2991 <br /> _ JULiRUNMENTAL HEALTH <br /> FaciLity Name: ` C � PERMIT/SERVICES <br /> Tank f Size Product <br /> Facility,'Address: 3 33c� /�.v Spm �- <br /> .. <br /> Telephone : y5— <br /> Person Filing <br /> Re p o r t <br /> 01 I hereby certify under penalty of perjury that all inventory variations for <br /> the above oeationed facility were within the .f1te�,Atile limits &ut this <br /> quarter. (No in Column 13 of 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 /> vas not due to as unauthorized (leak) releise. (Yes in Column 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/amounts shall be continued on a separate „heel of <br /> Paper and 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 1 - January --) March <br /> Quarter 2 - April --) June <br /> Quarter 3 - July --> September <br /> Quarter 4 - October --) Dc comber <br /> Send� to: SAN JOn QUIN LOCnt. HEAI,11i DISTRICT <br /> 1601 E . Hazelton . 1' .0 . ROx 2009 <br /> �(;T 40 L0IH6 Stockton , CA (15201 466-6161 <br />` <br />