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i <br /> INVENTORY RECONCILIATION <br /> QUARTERLY SUMMARY REPORT FORM APR <br /> r_NVIROViENTAL HEALTH <br /> Facility Name: /c. �C�•,� 1 Tank i >lse Product <br /> lacility,Address: l <br /> �,,� L <br /> Telephone : j / <br /> Person Filing_ <br /> Report ` -: ✓ ,Z; <br /> E] I hereby certify under penalty of perjury that all inventory variations for <br /> the above meationed facility were within the allowable limits for this <br /> quarter. (No is 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 Sheet) <br /> List date, tank /, and amount for all variations that exceeded the <br /> allowable limits. <br /> Date Tank f Amount y <br /> 9-- <br /> 3- J-13 If7676 <br /> 4. <br /> 5. <br /> AA ditional dateslamouots shall be continued on a separaCe 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 /> 1-he Quarterly aummacy report shall be aubmitced within 15 days of the end of cacti <br /> quarter. <br /> Quarter I - January --) march <br /> Quarter 2 - April --> Jurnc <br /> Quarter 3 - July --) September , <br /> Quarter 4 - October --) 04-cember <br /> Send to: SAN JOAQU I N LOCAL HEA1,11i DISTRICT <br /> 1601 E . HazcIto�n . P . O . Rox 2009 <br /> Stockton , CA 95201 466 -67bl <br /> T 40 10/ H0 <br />