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4INVENTORY RLCONCILIA' TION <br /> QUARTERLY SUMMARY REPORT FORM <br /> i"ac'ility Name: Tank # Size Product <br /> 1'aci1it,y Address: g e <br /> ''rlephone: <br /> 11;°rson Piling <br /> 1`!port: e <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 unauthDrized ( 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 . ECEIVED <br /> 2 , <br /> 3 . <br /> 4 Int l tJ E T L HEALTH <br /> PERMIT/ VICES <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 /> clue to a leak, the incident shall be reported to San Joaquin Local <br /> Health Districts Environmental Health Division, within twenty-four <br /> ( 24 ) hours and an unauthorized release report submitted. <br /> `1`11e quarterly summary report shall be submitted within. fifteen (15) days * <br /> of the end of each quarter. <br /> Quarter 1 - January---------->March <br /> ter 2 - <br /> April------------>June <br /> Quarter 3 July------ >September <br /> Quarter. 4 - October---------->December <br /> aZd to: SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 L. Hazelton, P.O. Box 2009 <br /> Stockton, CA 95201 468-3420 <br /> :,i 23 019 10/86 <br />