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INVENTORY RECONCILIATION OrT 1 ; W <br /> QUARTERLY SUMMARY REPORT FORK <br /> ENVIRUMI✓NTAL HEALTI-! <br /> FERiJiIT/SERVICES <br /> Facility Name: ! Tank # Size Product <br /> 0194i 'd WA <br /> fad 1Ltr Address L" Z 1, <br /> �r <br /> Telephone : <br /> Person Filing <br /> Report -L6cd <br /> e <br /> hereby ,certify under peaalty of.perjury that all inventory variations for <br /> the above mentioned facility were within the allowable Limits for this <br /> quarter- (No in Columm 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 is Column 13 of the <br /> Inventory Reconciliation Sheet) <br /> I <br /> List date, tank I, mad amount for all variations that exceeded the <br /> allowable limits. <br /> .. ..C.w.r--0..e Na te ��kaC"."••�r ■ M�r+.ti+rw+r r- - -ir.+c.��do..'_: __—_-_._ <br /> 2. <br /> 1. <br /> 3. <br /> 4. ,. <br /> Additional dates/amounts shall be continued on a separate sheet of <br /> paper and attached. <br /> 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_, Eovi-ronmenta-F-Hc-n eh- -- <br /> within 24 hours and an unauthorized_re lease report submitted. <br /> the quarterly summary report shall be submitted within 15 days of the end of each <br /> Quarter. <br /> Quarter I - Jaauary March <br /> Quarter 2 - April June <br /> Quarter 3 - July --> September <br /> Quarter 4 - October --> lk cember <br /> Send to: SAN JOAQU IN LOCAL HEALTH DISTRICT <br /> 160 l E. gaze l 1 ntl . P .O. BOX 1009 <br /> SLocktor , CA 95201 466-6781 <br /> UGT 40 10/86 <br /> I <br />