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Av A <br /> 9� <br /> INVENTORY RECONCILIATION OCT 4 1000 <br /> ENVIRONMENTAL HEA,-TIL i <br /> QUARTERLY SUMMARY RF-PORT FORM PERIv1i1/SER'• ICES <br /> Facility Name: � � �r1Rrau� HJT tank / <br /> _ Size Product <br /> Facility Address: / FVFG <br /> Telephone : !j_�o?3 9a S1 <br /> Person Filing <br /> Report ,C r//',e,LOYT4 <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. (No in Column 13 of the Inventory Reconciliation Sheet) <br /> ElInventory 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) releise. (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 / Amount <br /> 1. <br /> 2. <br /> 3. <br /> 4. <br /> / L5. <br /> Additional dates/amounts shall be continued D:, a separate sheet of <br /> oa Der and arra,h.d. <br /> If the source of the variation whichexceeded allowable limits was due to <br /> a leak the incident shall be reported to S .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 1 - 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 . Ilazellon , P . O . Box 2009 <br /> Stockton , CA 95201 466-6781 <br /> CT 40 10/86 <br />