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H�A RJ 9 9 A M I P M INVENTORY RECONCILIATION <br /> OCT 2 4 1.990 <br /> QUARTERLY SUMMARY REPORT <br /> .,/ ' :,- 1/1, FORM E4,k� GNMENTAL HEALTH <br /> Facility Name:-. ' Tank 9 S IPPM I T/g8g&fi5 <br /> -7 <br /> Facility Address : <br /> < <br /> Telephone: <br /> Person Fil�pg <br /> Report: T, <br /> w. 1� C),Z' f: � I <br /> I hereby certify under penalty of perjury that -all inventory variations <br /> ❑ for the above mentioned facility were within the allowable limits for <br /> this quarter. (No 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 varia- <br /> tion was not due to unauthorized ( leak) release. (Yes 4 <br /> the inventory Reconciliation Sheet ) . in Column 13 of <br /> List date, tank It , and amount for all variations that exceeded <br /> the allowable limits . <br /> Date Tank # Amount <br /> 1 . <br /> 2 . <br /> 3 . <br /> 4 . <br /> 5 . <br /> Additional dates/amounts shall be continued on a separate sheet <br /> paper and attached. <br /> If the source of the variation which exceeded allowable limits was <br /> due to a leak, the incident shall be reported to San Joaquin Local <br /> Health District; Environmental Health Division, within twenty-four <br /> ( 24 ) hours and an unauthorized release report submitted. <br /> The quarterly summary report shall be submitted within fifteen ( 15 ) days <br /> of the end of each quarter. <br /> Quarter 1 - January---------->March 'q?r. / 5 <br /> Quarter 2 - April------------>June �W I_S_ <br /> Quarter 3 - July------------->September <br /> Quarter 4 - October---------->December <br /> Send to: SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. Hazelton, P.O. Box 2009 <br /> Stockton, CA 95201 468-3420 <br /> Ell 23 019 10/86 <br />