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Facility Name: AA <br />Facility <br />Address: <br />�i <br />r <br />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 />❑ 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 unauthorized (leak) release. (Yes in Column 13 of 1.the <br />Inventory Reconciliation Sheet) "— <br />List date, tank #, and amount for all variations that exceeded the <br />allowable limits. <br />d <br />Date Tank # Amount <br />1. <br />2. <br />3. <br />4. <br />5. <br />Additional daces/amounts shall be continued on a separate sheet of <br />paper and attached. <br />If the source of the variation which exceeded at-lowable limits was due to <br />a leak the incident shall be reported to S.J•L.H.D. Environmental Health <br />Within 24 flours 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 - January --> March <br />Quarter 2 - April --> June <br />Quarter 3 - July --> September // <br />Quarter 4 - October --> December <br />Send to: SAN JOAQUIN LOCAL HEALTH DISTRICT <br />1601 E. Hazelton, P.O. Box 2009 <br />UCT 40 10!86 Stockton, CA 95201 466-6781 <br />., . .. ... r.�•s.. � ...: ...�...p • ..••,+ -.: ... -_ --. :. '. .•'."p.."'..•. .. � ""."'?'.. :vnwmx sxv sP.xjGYa.Kat1:7•; ',+�+YJ7 <br />