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�) <br />INVENTORY RECONCILIATION J�� 1r7 S8 - <br />QUARTERLY SUMMARY REPORT FORM OMENTAL ViEALTH <br />Facility Name <br />vv" IYlSERVIGES <br />Facility Address: 3 y <br />Telephone: �; L <br />Person Filing <br />Report 1 <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 as unauthorized (leak) release. (Yes in Column 13 of the <br />Inventory Reconciliation Sheet) <br />List date, tank /, and amount for all variations that exceeded the <br />allowable limits. <br />Date Sank I Amount <br />1. <br />2- <br />3. <br />4 <br />S. <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. 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 1. _January --) Marc <br />lQlarccr 1 =---A --> June A <br />Quarter 3 - July --> September <br />Quarter 4. - October --> December <br />Send to: SAN JOAQUIN LOCAL HEALTH DISTRICT <br />1601 E. IlazQllnn, P.O. Box 2009 <br />11CT 40 10/86 Stockton, CA 95201 466-6781 <br />