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INVENTORY RECONCILIATION ® C�j awl'. <br /> QUARTERLY SUMMARY REPORT FORM <br /> f� 1 <br /> EadUty. Name: Tank / Stca t PALTH <br /> fAcility?Address y5-1 C1 F . ACa�,p -7 - S raw <br /> Telephone : <br /> Person Filing <br /> Report -� r4 e IL- LLE I O C Q^ <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 Colum I3of the Inventory Reconciliation Sheet) <br /> r� <br /> m <br /> Inventory varistibas 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 unauthorised (leak) release. (Yes in Column 13 of the <br /> Inventory Reconciliation Sheet) <br /> List date, teak f, and amount for all variations that exceeded the <br /> allowable limits. <br /> Date Tank { Amount ( 7 �C <br /> t. 7/_5/F 7 307- a /0 7 /7/97 30-7- a <br /> 2. 7 /°7 i7 307- / 00-7 7/,90/87 307- <br /> 3. -7103187 30-7- a /`9Ut `7/ac.//87 307- a (, <br /> 4. -7 /a7 307- / 9sf 7/a9/s7 .307- / . <br /> 5. V/19 7 307-3 -50 -t 9/15/87 3q-7---'3 <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 at-lovable limits was due to <br /> a leak the incident shall be reported to S .J .L.H.D. Environmental Ncalth <br /> within 24 hours and an unauthorised release report submitted. <br /> The quarterly sueaary report shall be submitted within 15 days of the end of each <br /> quarter. <br /> Quarter 1 - January --> N3rch <br /> Quarter 2 - April --) June <br /> Quarter 3 - July --) September <br /> Quarter 4 - October --> December <br /> Send to: SAN JOAQUIN LOCAL HEALTH UIS'I'HICT <br /> 1601 E. Hazcl <<m , P .O . Box 2009 <br /> Stockton , CA 95201 466-6761 <br /> f 40 l0/A6 <br /> 9/ 5/67 307- / 103 - 9/ 7/87 307- / <br /> -7 , 9/a7&7 _/ 9/�9/�7 307-/ . <br />