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3 rt -1-' �r1nv <br />INVENTORY RECONCILIATION <br />QUARTERLY SUMMARY REPORT FORM <br />Facility Name: <br />Telephone: <br />Person Filing <br />Report <br />OCTRECEIVED <br />19 W <br />ENVIRONMENTAL HEALTH <br />PRMIVSERVICIE.S <br />ank It Size Prodact <br />a�—o Bou <br />I hereby certify under penalty;of rerury that all in.••e• rosy v••- t For <br />the above mentioned facility were within the allowable limits for this <br />quarter. (No in Colum= 13 of the Inventory Reconciliation Sheet) <br />LInventory variations exceeded the allowable limits ;or this quarter. I <br />hereby certify under penalty of perjury that the source for the variation <br />was not due to as unauthorized (leak) releise. (Yes in Column 13 of the <br />Inventory Reconciliation Shc,t) <br />List date, tank 1, and amount for all variations that exceeded the <br />allowable limits. <br />Date Tank f <br />Amount <br />1. 74- / <br />io 3 <br />2. 7/13 <br />3. -7/z <br />4- -J la, r i <br />zoy <br />a <br />l <br />Additional dates/amounts shall be continued or, a separate sheet of <br />paper and attached. <br />If the source of the variati(a 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 vithin 15 days of the end of each <br />quarter_ <br />Quarter I - January --) March <br />Q12rter 2 - April --> June <br />Quarter 3 - July --> Septemhi•r <br />Quarter 4 - October --> December <br />Send CO: SAN JOAQUIN LOCAL HEALTH DISTRICT <br />1601 E. Haz--1 <<�n , P .0 . Box 2009 <br />Stockton, CA 95201 466-6781 <br />EH 23 019 10/86 <br />