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1: vLNTORY RECONCILIATION <br /> QUARTERLY SUMMARY REPORT FORM <br /> Paacillty Name® <br /> f Tank Size odut <br /> ['acidity Address: a <br /> r'I aphone: r 2 v 6 <br /> �:.Pvirson Filing <br /> Repos z <br /> 1 ,hereby certify under penalty ofperjury <br /> P Y pex ]ury that clil znvt6nt6y vari,st. i r4E <br /> for the above mentioned facility were within the allowable limits <br /> this quarter. (No in Column13 of the Inventory Reconciliation' Sheco_ <br /> Inventory variations exceeded the allowable limits for this quarter. <br /> Hereby certify under penalty of per that the source for -the vari ,i <br /> tion was not due to unauthorized ( leak) release. (Yes in Column 13 ¢ <br /> the Inventory . Reconciliation Sheet) . <br /> List date, Lank #, and amount for. all variations that exceeded <br /> the allowable limits. <br /> Date 'Tank # Amount <br /> RECEI <br /> 2 <br /> JAN' t 8 9999 <br /> 3. <br /> ENVIRONMENTAL HEALTH <br /> 5. <br /> PERMIT/SERVICES <br /> Additional dates/amounts ;hall be continued on a separate sheat: <br /> paper and attached . <br /> I t ,'tiae source of the variation which exceeded allowable limits was <br /> clue' to a leak, the incident shall be reported to San Joaquin' Local <br /> Ito6ilth District; Environmental health Division, within twenty-four <br /> ( 24) hours and an unauthorized release report submitted. <br /> 'k"Ite quarterly su ary report shall be submitted within fifteen (15 ) days <br /> cal tlao and of each ' quarter. <br /> Quarter 1 - January---------->March <br /> Quarter 2 - April------------>June <br /> Quarter 3 - July---------_.-_-»cpternber <br /> Quarter-4 - October---M------->December <br /> t,End Lot. SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> ti <br /> 1601 E. Hazelton, P.O.. Box 2009 <br /> Stockton, CA 95201 468-3420 <br /> 4;Ct 23 019 '10/86 <br />