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HYEHTORY RECONCILIATION <br />m� <br />ARTERLY SUMMARY REPORT FORM <br />IP <br />r 1.} <br />Facility Hame. -y- <br />Facility Address;L9 -aak ,,(h <br />Telephone: <br />Person Filing„ <br />Report <br />ElI hereby certify under Penalty of perjury that all inventory variations For <br />the above a+eatioaed at <br />were within the allowable Limits for this <br />quarter. (Ho in Coluc3 13 of the Inventory &econciliacion Sheet) <br />QInventory variations exceeded the allowable Limits far this qu=rtes.. I <br />hereby certify under penalty of perjury that the Source for the variation <br />was not due CO an unauthorized (leak) release. (Yes in Colum= i3 of the <br />Inventory Reconciliation Sheet) —"' <br />List date, tank I, :aexceeded thed amount for all variations that <br />allowable limits. <br />Date Trak <br />® Amount <br />--. -- <br />2_ <br />4• <br />5. <br />Additional dates/amounts ShaLl be continued ®a a separate sheet of <br />PaPer and attached. <br />If the source of the variation which exceeded allowable limits was due to <br />= leak the incident shall be reported to <br />within 24 hours and an unauthorized release_ J.L.H•.D Eavidonzental Health <br />reporThe quarterly summary report shall be submitted within 15 days of the end of <br />qu=rcer. <br />each <br />Quarcer 1 - January --> Harch <br />Quarter 2 — April —.> June <br />Quarter 3 - Ju Ly —> September <br />Quarter 4 October —� December <br />Send t®; SAN JOAQUIN LOCAL HEALTH DISTRICT. <br />1601 E. Hazelton, P.O. Box 2009 <br />1CT 40 10/86 Stockton, CA 95201 466-6781 <br />wr-`;..jam .. - ..:'. 'C•, +- _�:.�:.5:c:�.' •:.:: "....77_a.....�.. <br />