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"I • INVENTORY R13CONCILIATION• <br /> QUARTERLY SUMMARY REPORT FORM <br /> Facility Name: Tank # Size Product <br /> v\ J- <br /> Facility Address: - L p 2 U <br /> yA <br /> 3 \ o -P- <br /> Telephone _ 2�P <br /> Person Filing <br /> Report: . ,_ <br /> I hereby certify under penalty of perjury that all inventory variation: <br /> for the above mentioned facility were within the allowable limits for <br /> this quarter. (No in Column 13 of the Inventory Reconciliation Sheet. . <br /> Inventory variations exceeded the allowable limits for this quarter. ] <br /> ❑ hereby certify under penalty of perjury that the source for the varia- <br /> tion was not due to unauthorized ( leak) release. (Yes in Column 13 of <br /> the Inventory Reconciliation Sheet) . <br /> List date, tank # , and amount for all variations that exceeded <br /> the allowable limits . <br /> Date Tank # Amount <br /> is a.0 a r a <br /> 6 Z <br /> 2 . ; <br /> 3 . JAN 2 3 1?�D <br /> Fn111 <br /> 4 • AIMENTAL HEALTH <br /> PERMIT/SERVICES <br /> s. <br /> Additional dates/amounts shall be continued on, a separate sheet <br /> paper and attached. <br /> if the source of the variation which exceeded allowable limits was <br /> due to a leak, the incident shall be reported to San Joaquin Local <br /> Health District; Environmental Health Division, within twenty-four <br /> ( 24 ) hours and an unauthorized release report submitted. <br /> The quarterly summary report shall be submitted within fifteen ( 15 ) days <br /> of the end of each quarter. <br /> Quarter 1 - January---------->March <br /> Quarter 2 - April------------>June <br /> Quarter 4 - October---------->December �q`8 <br /> Send to: SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 r. Hazelton, P.O. Box 2009 <br /> Stockton, CA 95201 468-3420 <br /> Ell 23 019 10/86 <br />