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IRECEIVEL <br /> APR 510^' <br /> INVENTORY RECONCILIATION -'!E-WiR0NME-NTAL-HEAc4-l--- <br /> PERM11/SERdiOES <br /> QUARTERLY SUMMARY REPORT FORM , <br /> Facility Name: Tank 0 <br /> Sire Product <br /> Ficil47,Address, <br /> Telephone : > cgg '7 <br /> Person Filing <br /> r 'Alit) lv <br /> � 1 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. (Ho in Column 13 of the Inventory Reconciliation Sheet) <br /> ❑ inventory variations exceeded the allowable limits for tbi• quarter. I <br /> hereby certify under penalty of perjury that the source for the variation <br /> was not due to as unauthorized (leak) releise. (Teff in Column 13 of the <br /> Inventory Reconciliation Sheet) _ <br /> List date. tank 0, and amount for all variations that exceeded the <br /> allowable limits. <br /> Date Tank 0 Amount <br /> 1. <br /> a. <br /> 3. <br /> 4. ' <br /> 5. <br /> Additional dates/amounts chall 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 --) Septcmhcr <br /> Quarter 4 - October --) Orcember <br /> Send to: SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. Hazeltnn . P .O . Box 2()()9 <br /> Stockton . CA 95201 466-6761 <br /> EH 23 019 10/86 <br />