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INVENTORY RECONCILIATION JAN 1 0 <br /> QUARTERLY SUMMARY REPORT FORM ENVIRONMPITAL HE:ALTH <br /> f'N e7 <br /> PERMI ITI.,""Fr)'�1 <br /> Facility None'. e40 Tank # Size Product <br /> Facility Address; Wot n- 5t. <br /> AF,9.,1Fec5—T-5, <br /> Telephone : 00c(- <br /> Person Fi; ng <br /> Report 1%�f lf,4%, J- <br /> t ZVO 1/1 O's <br /> --4f Ll�— <br /> E] 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. (go in Column 13of 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 /> vas not due to an unauthorized (leak) release. (Yes in Column 13 of the <br /> Inventory Reconciliation Sheet) <br /> List date, tank #, and amount for 211 variations that exceeded the <br /> ff <br /> allowable limits. <br /> Date Tank f Amount <br /> 2. /0) I qc�o <br /> 3. <br /> 4. <br /> 5. <br /> Additional dates/amounts shall be continued .on 2 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 /> Quarter I - January March <br /> Quarter 2 - April June <br /> Quarter 3 - July September <br /> Quarter 4 - October Ik-cember <br /> Send to: SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E . Haze lLcin , P .O . Box 2009 <br /> Stockton , CA 95201 466-6781 <br /> UGT 40 10/86 <br />