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"VENTORY RUCONCILIA1TIONJUL 04 <br /> QUARTERLY SUMMARY REPORT FORM <br /> E-NVIMWENTAL HEALTH <br /> Facility Name:C ' C Tank # S . rr1.SMigauct <br /> Facility Address: L <br /> `"elephone; <br /> Person filing a c sous` <br /> Report: <br /> I hereby certify under penalty of perjury that all. inventory variations <br /> for the above mentioned facility were within the allowable limits for <br /> this 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 varia- <br /> tion was not due to unauthorized ( leak) release. (.Yes in Column 13 of <br /> the Inventory Reconciliation Sheet) . <br /> List date, tank # , and amount for all variations that exceeded <br /> the 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 sheet <br /> paper and attached. <br /> if the source of the variation which exceeded allowable limits was <br /> due to a leak, the incident shall be reported to San Joaquin Local <br /> health District; Environmental Health Division, within twenty-four <br /> ( 24 ) hours 'and an unauthorized release report submitted. <br /> The quarterly summary report shall be submitted within, fifteen (15 ) days <br /> of the end of each quarter. <br /> Quarter 1January---___..___>March <br /> QuaZD- pril--______--__>June <br /> Quauly_--- ----- -->September <br /> Quarter. 4 - October---------->December <br /> Send to: SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 B. Hazelton, P.O. Box 2009 <br /> Stockton, CA 95201 468-3420 <br /> III 23 019 10/86 <br />