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'YENTORY RECONCILIATION <br />QUARTERLY SUMMARY REPORT FORM <br />RICHArM OfIKID73 <br />Facility Name:SAME Eity . , <br />:. F e <br />E PADDOCK PLACE <br />Facility Addce8Mecrnr1: C P- Z <br />r.'nernv � <br />Lom t_, Ir c -,?An <br />Telephone: (209) 334 0975 <br />Person Filing <br />Report <br />EEL.,urrm <br />E <br />I 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 Recoaciliatioa Sheet) <br />Qjuventa Variations cx-ce-ded the allowable !Lmits for thie q= �,I�, •• <br />hereby certify under penalty of perjury that the source far t�iation., <br />was not due to an unauthorised (leak) release. (Yes in CohWkb`of-��.� <br />Inventory Reconciliation Sheet) <br />List date, tack tv and amount for all variations that exceeded the <br />allowable limits. <br />Date Tank # Amount <br />2. <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 reporced to S,J.L.H.D. Euvirormental health <br />within 24 hours and as unauthorized release report submitted. <br />The quarterly summary report shall be submitted within 15 days of the cad of each <br />quarter. <br />Quarter 1 - January --> March <br />Quarter 2 - April --> June <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 466-6781 <br />UGT 40 10/86 <br />