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0 6 <br />INVENTORY RECONCILIATION <br />QUARTERLY SUMMARY REPORT FORM <br />Facility Name: ? 5yoCRE <br />Tank <br />Facility Address: <br />Telephone: Stitt-%I� <br />Person Filing <br />Report P lC' <br />c <br />�', f, -•� � VVV <br />7 <br />APR 1 D7 <br />ENVIROPOENTAL HEALTH <br />FERroiT/SERVICES <br />E] 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 l3 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 1, and amount for all variations that exceeded the <br />allowable limits. <br />Date Tank f Amount <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 .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 />January March <br />Quarter 2 - Apr -i(-- =s7une -- <br />Quarter 3 - July September <br />Quarter 4 - October December <br />Send to: SAN JOAQUIN LOCAL HEALTH DISTRICT <br />1601 E. Hazelton, P.O.. Box 2009 <br />Stockton, CA 95201 466-6761 <br />UGT 40 10/86 <br />