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INVENTORY RECONCILIATION I }_ <br /> QUARTERLY SUMMARY REPORT FORM ENVI Rom <br /> UNTAL HEALTH <br /> 1 <br /> ,/ -ff F ERPF I SERVICES <br /> Facility Name: I(4(7 /J I 'Aa Tank Size Product <br /> 0 -7 <br /> Facility Address: rife 1;1 C <br /> A-74 V CW--Q Cr6 3 3 6 <br /> Telephone : coq .2 act-Ss(p I <br /> Person Filing _ <br /> ReportP/'/`5/. <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 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 /> vas not due to an unauthorized (leak) release. (Yes in Column 13 of the <br /> Inventory Reconciliation Sheet) <br /> Lust date, tank It and amount for all variations that exceeded the <br /> allowable limits. <br /> Acte Tank # Amount <br /> /'Votes ih P AS' <br /> *2 s <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 /> Quarter I - January --> March <br /> Quarter 2 - April --> June <br /> Quarter 3 - July --> September <br /> Quarter 4 - October --) December <br /> Send to: SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601. E . Hazc 1 t oii , P .O . Box 2009 <br /> Stockton , CA 95201 466-6751 <br /> UGT 40 10/86 <br />