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_ [��� _ <br /> `H Y <br /> 4 � J u L-AA <br /> INVENTORY RECONCILIATION JAN 1 6 TSO <br /> QUARTERLY SUMMARY REPORT FORM ENVIRON ME4N1AL HEALTH <br /> PERMIT/SERVICES <br /> Facility Have: X\J Nl tank 1 Size Product <br /> NJ 00 O U Z-&-DE <br /> FACM'tly<Addresa: . W .�y u� <br /> - <br /> Telephone : oda <br /> Person Filin // / <br /> Report _L4�do/l/ _ P Avl� <br /> �Ihereby 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 this quarter. I <br /> hereby certify under penalty of perjury that the source for the variation <br /> was not due to an unauthorized (leak) release. (Yes in Column 13 of the <br /> Inventory Reconciliation Shecc) <br /> List date. tack It and amount for all variations that exceeded the <br /> allowable limits. <br /> Date Tank E Amount <br /> 1. <br /> 2. <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 at-lovable 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 unauthorised release report submitted. <br /> The Quarterly summary report shall be submitted within IS days of the end of each <br /> Quarter. <br /> Quarter 1 - January --) March <br /> Quarter 2 - April --> June , <br /> Quarter J - July --) Scptemher <br /> Quarter 4 - October --) December <br /> Send to: SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. liazelLoll . P .O. Box 2009 <br /> Stockton , CA 95201 466-67b1 <br /> EH 23 019 10/86 <br />