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IAPR 15197 <br /> INVENTORY RECONCILIATION ENVIROMENTAL HEALTH <br /> QUARTERLY SUMMARY REPORT FORM PERMIT/SERVICES <br /> Facility Name: � ,(lj <br /> \1` ,, l Tank i Size Product <br /> Facility Address: <br /> Telephone : (�q ) - ("A <br /> Person Filinpx—_ I I <br /> Report �\i Tk—o {•'{;ko <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. (Ho in Column 13of the Inventory Reconciliation Sheet) <br /> E] Inventory variations 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 unauthorized (leak) release. (Yes in Column 13 of the <br /> Inventory Reconciliation Sheet) <br /> List date, tank 1, and amount for all variations that exceeded the <br /> allowable limits. <br /> Date Tank I Amount <br /> 1. <br /> 2- <br /> 3. <br /> 4. <br /> 5. <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 summary report shall be submitted within 15 days of the end of each <br /> quarter. <br /> �Qua� rt 1; - January --) March i�n1 <br /> Qiar eer 2 - April --> June <br /> Quarter 3 - July --> September <br /> Quarter 4 - October --> December <br /> Send to: SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E . Hazelton , P . O . BOX 2009 <br /> Stockton , CA 95201 466-6781 <br /> UGT 40 10/86 <br />