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D a� <br /> P <br /> INVENTORY RECONCILIATION OCT 21 iaR7 <br /> QUARTERLY SUMMARY REPORT FORM ENVIRONAENTAL HEALTH <br /> F ERlJItT/SERVICES <br /> FaciILty Names mum P� a/�(� Tank i Size, <br /> Product <br /> Facility,,Address: 3a,l Z Alf Ca-11 ;-Orsi a- <br /> / Coq 9 e <br /> Telephone : <br /> Person Filingf <br /> Report �Da _r?r)AL <br /> 0 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. (No in Column 13 of the Inventory Reconciliation Sheet) <br /> EY"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 i, and amount for all variations that exceeded the <br /> allowable limits. <br /> Date Tank f Amount <br /> 1. l f l3 s <br /> i. j-2 l3 z <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 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 --) September <br /> Quarter 4 - October --> December <br /> Send to: SAN JOAQUIN LOCAL HEALI.1i DISTRICT <br /> 160L 1. . I;aze 1 l (ln , P . O . liox 2009 <br /> SLockton ,- CA 95201 466 -6781 <br /> UCT 40 10/ 80 <br />