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racixityName: <br />Facilit Address: <br />Z:) <br />Te lephone: <br />Person ng <br />Report <br />I hereby certify under penalty of perjury that al'I inventory variatioa <br />If <br />the above mentioned facility were within the allowable limits for thliss <br />quarter. (No in Column 13of the Inventory Reconciliation Sheet) I <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) rele�se. (Yes in CoLumn13 of the <br />Inventory Reconation sheet) <br />List date, tank 1, 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 contiaued on a separate sheet of <br />paper and attached. <br />If the source of the variation which. exceeded at-lowabte 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 />Quarter 2 - April June <br />Quarter 3 - July Septcmhcr <br />Quarter 4 - October December <br />Send to: SAN JOAQUIN 1,0CAL HEALTH DISTRICT <br />1601 E. Hazelton. P.O. Box M09 <br />SLockton, CA <br />95201 466-67bl <br />40 10/86 <br />