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i &j4 <br /> N M�I <br /> ' i'iENTAL HEAL-:-1; <br /> INVENTORY RECONCILIATIO �r'r{r �1�1/!CE <br /> QUARTERLY SUMMARY REPORT FORM <br /> 93 .1(�G -a Pfd 2: 27 <br /> FaciLity, Names _ /w% lP/Y� c /?(, Tank i Size. <br /> Product <br /> Facilit 'Addresst / <br /> c�� c' <br /> Telephone : <br /> Person Filing <br /> Report <br /> E] I hereby certify under penalty of perjury that all inventory variations for <br /> the above mentioned facility were vithin the allowable limits for this <br /> quarter. (Ko in Column 13 of the Inventory Reconciliation Sheet) <br /> Inventory variations exceeded the allovable 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 f, and amount for all variations that exceeded the <br /> allowable limits. - <br /> Date Tank f Amount <br /> 3. ICS <br /> 4- 1 <br /> 5. <br /> Additional dates/amounts shall be continued an a separate sheet of <br /> paper and attached. <br /> If the source of the variation which. erceeded allowable limits was due: to <br /> it 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 Kubmitted within IS days of the end of each <br /> Quarter. <br /> Quarter I - January --) March <br /> Quarter 2 - April --) June <br /> Quarter 7 - July --> September <br /> Quarter 4 - October --> December <br /> Send to: SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E . haze 1 Loin , P . O . Box 2009 <br /> Scockton ,- CA 95201 466 -6181 <br /> ;T 40 10/ 86 <br />