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INVENTORY RECONCILIATION <br /> QUARTERLY SUMMARY REPORT FORM ` AN ' i98L <br /> Faetiity Names <br /> q� CNVIROFi ENTAL HEALTH <br /> '/r/Y,5' � - <br /> Tank I roduct <br /> S eW <br /> Facilipy4ddress: 13 <br /> 20 W . ((1 1Ier <br /> Telephone : 416, <br /> Person Filing <br /> Report <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 Column I1 of the Inventory Reconciliation Sheet) <br /> 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 act due to an unauthorized (leak) release. (Yes in Column 13 of the <br /> Inventory Reconciliation Sheet) <br /> List date# tank /v and amount for aIL variations that exceeded the <br /> allowable limits. <br /> Date tank f 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 whichexceeded 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 /> Quarter I - January --) March <br /> Quarter 2 - April --) June <br /> $sa-ctst,] _ - July --) September <br /> Quarter 4 October --> December /s/'��7 <br /> Send to: SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 160L E. Ilaze1LIM , P .O . Box 2009 <br /> Stockton , CA 95201 466-6761 <br /> 11('T 40 10/ 86 <br />