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INVENTORY RECONCILIATION <br />QUARTERLY SUMMARY REPORT FORM <br />Facility Name; <br />yl <br />Facility Address: <br />Telephone: o <br />Person Filing <br />Report <br />I hereby certify under penalty of <br />the above mentioned facility were vithiny that all <br />quarter, inventory variations for <br />iHo in Column 13 of the the '!lovable limits <br />Inventory Reconciliation Sheet) <br />r this <br />Inventory variations exceeded the allowable limits for <br />hereby certify under penalty of perjury that <br />was not due to ao unauthorized this quarter. I <br />(leak) releisethe source for the variation <br />Inventory Reconciliation Sheet) (Yes 1° <br />Column 13 of the <br />ENVIRUfint,\-IAL HEALTH <br />1' ERrvtlr <br />List date, tank /, and amount for all <br />allowable 11011 C8. variations that exceeded the <br />Date Tank / <br />Amount <br />1. 7-7- <br />3 1�3 8e <br />2. -) - -) <br />3. <br />4. �— <br />cS�cuc�ern <br />(� `A'�- <br />Additiooal daces/amounts shall b <br />Paper and attached. a continued oo a separate sheet of <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 <br />quarter. <br />of each <br />Quarter 1 - January --) <br />Qaar_ter 2 _ March <br />April --> June <br />Julr --> Scptemh�� <br />�[uarter 4 - October --> <br />December <br />Send to: SAN JOAQUIN LOCAL HEALTH DISTRICT <br />1601 E. Hazelton, P.O. Box 2()09 <br />ICT 40 10/86 Stockton, CA 95201 466-6761 <br />