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l INVENTORY RECOttCIL IATION OCT "1"1 <br /> v VI QUARTERLY SUMMARY REPORT FORM �J' ` I)( \j`;,i 's %A�T 'I <br /> 1P&MIT!'ERVICES <br /> Facility N3mc: k STbP -** I 3 Z <br /> tank / Sizes <br /> _ Product <br /> Pic tty Addreae: ��� %a ot• , .nCG <br /> ,Sl U c ,e 74)ti C.I %S.�c 9 <br /> !/YNL <br /> Telephone : 209- s� <br /> Person Filing <br /> R e p o r C <br /> FrL hereby certify under penalty ofer u <br /> p ) ry that all inventory variations For <br /> the above mentioned facility were within the allowable limits for this <br /> Quarter. (No in Column 13of the Inventory Reconciliation Sheet) <br /> ElInventory variations exceeded the allowable limits for this quarter. <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 1, and amount for all variations that exceeded the <br /> allowable limits. <br /> Date Tank E Aawunt <br /> i . <br /> 2- <br /> 3. <br /> 4. <br /> S. <br /> Additional dates/amounts shall be continued oo a separate sheet of <br /> Paper and attached. <br /> If the source of the variation which exceeded allowable limits vas due to <br /> leak the incident shall be reported to S .J . L. H . D. Environ-ental liealth <br /> within 24 hours and an unauthorized release report submitted. <br /> nuc ,7uarterly sucanary report shall bar submi [[e�f within 15 day; of Che t-nd of <br /> q,i.�rcrr <br /> Quarter I January Harch <br /> Quarter 2 - April --> June <br /> Quarter 3 - July _-� <br /> :,cPtCmbr.r <br /> Ql,arter 4 - October <br /> amend toe SAN JOAQUIN LOCAL HEALTH [)IST'RIC1' <br /> 1601 E . Hazelton , P . 0 Box 2009 <br /> 11CT 40 10/$6 Stockton , CA 95201 466-6781 <br />