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INVENTORY RECONCILIATION E 1 ? 19a <br /> QUARTERLY SUMMARY REPORT FORK ENVIKO�E'�TAL HEALTH <br /> y� PERMIT/5ERVICES ` <br /> Facility Name: "` <br /> a)�ki T <br /> ank Product <br /> facility Address: ► <br /> Telephone : S <br /> Person Fi ng <br /> Reporc <br /> I hereby certify under peoalt of <br /> the above 7 perjury that all inventory variations for <br /> mentioned facility were within the allowable limits for this <br /> quarter. (No in Colum D of the Inventory Reconciliation Sheet) <br /> Inventory variations exceeded the allowable limits for this quarter. 1 <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 /> � I <br /> List dater tank /r and amount for all variations that exceeded the <br /> allowable limits. <br /> Date Tank I Amount <br /> 1 <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 sum ry report shall be submitted within <br /> quarter. IS days of the end of each <br /> Quarter I - <br /> janugry --) H.1rch <br /> .a tier 2 - Anril _) J <br /> Quarter 3 - July --) jeptemhcr <br /> Q%Aarter 4 - October --) December <br /> Send to: SAN JOAQUIN LOCAL HEALTH UISTRIC'1- <br /> I 160 1 I:. Ilaze l t on . 1' .0 . 8ox 211(19 <br /> " Stockton , CA 95201 466-67bl <br /> 111:1' 40 10/N6 <br />