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0 r 3, , <br />INVENTORY RECONCILIATION F <br />?0 0, <br />QUARTERLY SUMMARY REPORT FORM �`�p "'(7p <br />1� �� <br />PEh�tiC,F <br />5.,.:., <br />FaesLity. Name; V1lLAGE VV ARCD <br />Me r . �Iqcmln o , <br />licitie Addcess; Stockton, CA 95207 <br />, <br />Telephone: 7-777-777 <br />Person Filing <br />Report -,H YU <br />I hereby certify under <br />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 />0 Inventory 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 an unauthorised (leak) releise. (Yes in Column 13 of the <br />Inventory Reconciliation Sheet) _ <br />List date, tank #, and amount for all variations that exceeded the <br />allowable limits. <br />Date Tank f Amount <br />1. <br />2. <br />3. <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 shal l be reported to S. J , L. H. D. Environmenta 1 Hca 1 t <br />Within 24 hours and an unauthorized release report submitted. <br />The Quarterly summary report shall be submitted within 15 days of the end of each <br />Quarter. <br />Quarter 1 <br />- January <br />--> March <br />Quarter 2 <br />- April <br />--) June <br />Quarter 3 <br />- July <br />--> September <br />Quarter 4 <br />- October <br />--> December <br />Send to: SAN JOAQUIN LOCAL HEALTH DISTRICT <br />1601 E. Hazelton. 1' . 0 . Box 2009 <br />1CT 40 lO/RG Stockton. (.A 95201 466-6741 <br />