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INVENTORY R j �0 <br />ECONCILIATION <br />QUARTERLY SUMMARY RFPORT FORM <br />Facility Name: <br />Facility Address: S Telephone: , ._3 <br />Person Fi ing <br />Report <br />761 <br />I' #.' 1. 1 " 1988 <br />ENVIROMENTAL HEALTH <br />I- ERic11T/SERVICF-R <br />I hereby certify under penalty of perjury that all inventory variations for <br />the above mentioned facility were within the allowable limits for 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 />was not due to an unauthorized (leak) release. (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 <br />Amount <br />3. <br />4. <br />5. <br />Additional dates/amounts shall be continued on a separate sheet 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. Enviro <br />Within 24 hours and an unauthorized release report submitted,nmcntal Health <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 --> <br />Quarter 4 $cpeemher <br />- October --) December <br />Send to: SAN JOAQUIN LOCAL HEALTH DISTRICT <br />1601 E. HaZellnn, P.O. liox 2009 <br />IICT 40 10/86 Stockton, CA 95201 466-6781 <br />1, xxsa. o r u-" V- <br />1 S T F w <br />be�o.>,.�s_ec%- <br />Se"r ire Pxroy- <br />