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[NYENTORY RECONCILIATION <br /> QUARTERLY SUMMARY RFPORT FORM <br /> �Vtr� 'a! H.=ALTH <br /> Facility Name: 7' f�Un/. �s�- Mt:u <br /> Facility Address: /&� <br /> ,5179 W'-00 <br /> Telephone : :/!o 3 - P-V 3 <br /> Person Fg <br /> Re p o r t <br /> 1 hereby certify under penalty of perjury that all inventory variatioas for <br /> the above meationed facility were within the allowable limits for this <br /> quarter. (No in Columa 13 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 /> van not due to an unauthorized (leak) releiae. (Yes in Column 13 of the <br /> Inventory Reconciliation Sheet) <br /> List date, tank i, aad amount for all variations that exceeded the <br /> allowable limits. <br /> Date Tank I Amount <br /> I. <br /> 2. <br /> 3. <br /> 4. <br /> 5. <br /> Additional dates/amouats 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 /> atter I - Jaauary --) March <br /> Quarter 2 - April --> June <br /> Quarter 3 - July --) Scptemhcr <br /> Quarter 4 - October --) 1k comber <br /> Send to: SAN JOAQUIN LOCAL HEALI'li DISTRICT <br /> 160L L . Hazelton . P .O . Rox 2009 <br /> UCT 40 10/86 Stockron . CA 95201 466 -6761 <br />