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INVENTORY RECONCILIATION <br /> QUARTERLY SUMMARY REPORT FORM "uL i 158, <br /> ®� MENtAL HEALTH <br /> ` acL �� 6 CaRNnryE SVRn Yank t St e. 1 oduet <br /> 1000 GAL U[JLEAD <br /> Pd�Addreset _78600 CORRAL HOLLOW RD 2 1000'GAL. D <br /> 1.'-'RACY _ Cn 95378 01105 <br /> Telephone : 415 455 5918 <br /> Person Filing a <br /> Report <br /> X hereby certify under penalty of perjury that all inventory variations for <br /> the above mentioned facility uere within the allowable ldaits nor thio <br /> quarter. (No in Coluou 15 of the Inventory Reconciliation Sheet) <br /> U Inventory variatieos exceeded the Allowable linita for thin Quarter. ' 'I <br /> beceby certify under penalty of perjury that the source for the variation <br /> Was act aur to an unauthorized (leak) release. (Yes is Colman 13 of the <br /> Inventory Reconciliation Sheet) <br /> List date, tank 0, and amount for all variatioon that exceeded the <br /> allowable limits. > <br /> Date Tank 0 Amount <br /> 1. <br /> 3. <br /> 4. <br /> 5. <br /> Additional dates/amounts shall be continued no 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 .7L.H.D. Environmental Health <br /> %sithin 24 hours and an unauthoriaed 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 --> "larch <br /> Quarter 2 - April --> June <br /> Quarter ] - July --> ,September <br /> Quarter 4 - Octobcr --> bccember <br /> Send to: / SAN JOAQUIN LOCAL HEALTH DISTRICT ' L <br /> 1601 E . Itarellrow , P .O. llox 2009 <br /> Stockron , CA 95.1.01 466-6761 e <br /> T 40 10/86 <br />