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INVENTORYON <br />QUARTERLY REPORT <br />facility Ram: .. <br />Lic <br />Telephone: <br />ReportPerson F� <br />• ,• <br />0 I berebp certify un4er penalty of perjury that all inventory varia-f-s".0 <br />the above vmmtioned facility were within the allowable limits for this.:: <br />4tuartec* (No in Column 13of the Inventory Reconciliation Sheet) ucr `} <br />E/V <br />Inventory variations exceeded the allowable ' limits for thin quart <br />hereby certify under penalty of perjury that the source for the varia CL; <br />was Got due to an unauthorised (leak) release. (Yes in Column 13 of the <br />In"atory Reconciliation Sbeet) , <br />List tet- tank i, and amount for all variations that exceeded the <br />allowable limits. <br />Date Tank # Amount <br />1. r .._ <br />2. 15 q <br />4. ..: <br />s �,- ��{p�'� 1642, <br />• • � <br />• 0 <br />Additional dates/amounts shall be continued on a separate sheet of <br />paper and attar d. <br />Y <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 Uealth <br />Within 24 hours and an unauthorised release report submitted. <br />The quarterly summary report shall 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 --> Septeaher <br />Quarter 4 October --> Deccwer <br />Send to: SAN JOAQUIN LOCAL HEALTH DISTRACT <br />1601 E Haz lion, P.O. Box 2009 <br />Stockton, CA 95201 466-6781 <br />` UGT 40 10/86 <br />