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r rti <br /> INVENTORY RECONCILIATION b` ` tfF <br /> QUARTERLY SUMMARY REPORT FORM / MARr2 <br /> ENlIRON�1c.N T,4 1 � <br /> !?utility Dawe: (� <br /> r Tank Rradu t <br /> tscility Address: <br /> 15 <br /> 0 s� <br /> v <br /> Telephone: <br /> Person Filing 1` <br /> Report <br /> I hereby certify under penalty of'perjury that all iwnmtort variations for <br /> the above mentioned facility were within the allowable Limits for this <br /> ---.quarter. --(�1o�L+s_Coluaa_13of_the..-Inventory.-leeosseiliatioa 8beet) , <br /> QInventory variations exceeded the allowable Limits for this quarter. I <br /> hereby certify ander penalty of perjury that the Soares for the vsri4stior <br /> was mot dare to an unauthorized (leak) release. (Yalu in Color 13 of the <br /> Inventory Reconciliation sheet) <br /> Liat date, tank #, and amount for all variations that ezeeeded,the <br /> allowable limits. <br /> Date Tank # AmMut <br /> 3. f '/VT� <br /> 4. <br /> s. <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. Eoviroamental Health <br /> within 24 hours and an unauthorised release report submitted. <br /> The quarterly summary report shall be submitted within 15 days of the end of each <br /> quarter. } <br /> 11, ua <br /> Qrter # •- January --� March <br /> I <br /> Quarter 2 - Pori ane <br /> Quarter 3 - July —> September <br /> Quarter 4 s-- 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 />