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INVENTORY RECONCILIATION RECEIVED <br />QUARTERLY SUMMARY REPORT FORM <br />- ENVIRONMENTAL HEALTH <br />Wftf Benlamin R1711 Dr <br />PersonTelephone: ==77 =77 <br />i• <br />,eport �&Vj Z22,:5 -X -,q&-2 <br />0-- 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 Reconciliation Sheet) <br />Iaveatory variations exceeded the allowable limits For this quarter. I <br />hereby certify under penalty of perjury that the source for the variation <br />was not due to as unauthorized (leak) release. (Yes in Column 13 of the <br />Inventory Reconciliation Sheet) <br />List date, Caak f, and amount for all variations that exceeded the <br />allowable limits. <br />Date Tank ! Amount <br />1. <br />2. <br />3. <br />4. <br />5. <br />Additional dates/amounts shall be continued on : 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 . Environmental Health <br />within 24 hours and an unauthorized release report submitted. <br />The quarterly summary report shalt be submitted within 15 days of the end of each <br />quarter. <br />Quarter I - January --) March <br />Quarter 2 - April --? June <br />Quarter 3 - July --) September <br />Quarter 4 - October --> J)ecember <br />Send to: SAN JOAQUIN LOCAL HEALTH DISTRICT <br />1601 E. Hazelton, P.O. Box 2009 <br />Seoekton, CA 95201 466-6761 <br />LICT 40 10/86 <br />