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,mJNYENTORY RECONCILIATION 0 <br />RTERLY SUMMARY REPORT FORM <br />. Facility Name : <br />Facility Address: <br />Telephone: <br />Person Filing <br />Report <br />I hereby certify under penalty of perjury that all inventory variations for <br />the above mentioned facility were within the allowable limits <br />quarter. (No in Column i3 of the Infor this <br />ventory Reconciliation, Sheet) <br />QInventory variations exceeded Che allowable Limits for this quartere-,a <br />hereby certify under penalty of perjury that the source for the vzr_i$Caoa <br />wan Doc due to an unauthorized (leak) release. (Yes in COlumn 13 of the <br />Inventory Reconciliacioo Sheet) '� <br />List date, tack 1v and amount for all wariacioos that exceeded the <br />allowable limics. <br />Date Tank f Amount <br />2. <br />4. <br />5. <br />Additional daccS/amounts shall be continued on a separate sheet of <br />Paper and attached. <br />If the source of the variation which exceeded allowable limits was due to <br />a leak the incident shall be reported to <br />within 24 hours and an unauthorized releas.J H•sD Environmental Healch <br />The quarterly summary report shall be submitCed with <br />quarter. in I$ days of the end of <br />each <br />Quarter 1 "---January --> March <br />Quarter 2 <br />April —> June <br />Quarter 3 - July —> September <br />Quarter 4 - October —, December <br />send t®: SAN JOAQUIN LOCAL HEALTH DISTRICT <br />1601 E. Hazelton, P.O. Box 2009 <br />ICT 40 IO/86 Stockton. CA 95201 466-6781 <br />