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INVENTORY RECONCILIATION <br /> QUARTERLY SUMMARY REPORT FORM <br /> Facility Name: ' v ` �j Tank B Size Product <br /> Facility Address : S.Zp ( 01 osoo e <br /> u <br /> Telephone: !Z noo <br /> Person Pilin <br /> Report: , ti <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 /> p <br /> Date r, r n", o <br /> a <br /> Tank $ Amount1. ��t$ � t <br /> �,ta <br /> 2 . JAN 2 3 1-O98 <br /> ---crvVIRONMENTAL HEALTH <br /> 3 PERMIT/SERVICES <br /> 4 . <br /> 5. <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 3 - July------------->September <br /> Quarter 4 - October---------->December 19 <br /> Send to: SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 B. Hazelton, P.O. Box 2009 <br /> Stockton, CA 95201 468-3420 <br /> lilt 23 01.9 10/86 <br />