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ONVENT*ORY RECONCILIATION <br />JUARTERLY SUMMARY REPORT FORM <br />.gaaa� l / ati YI11 <br />Facility Name: r <br />MA <br />Telephone: <br />L <br />Person Ming <br />Report <br />❑r <br />G -1 <br />I hereby certify under penalty of perjury that all invea <br />the above mentioned facility were within the allowable 1 s r t i <br />quarter. (No in Column13 of the Inventory Reconciliation Sh J <br />ENVI �ENS ��.. <br />Inventory variations exceeded the allowable'limits for this quarter. Z <br />hereby certify under penalty of perjury that the source for the variation <br />was not due town unauthorized (leak) release. (Yes in Column 13 of the <br />Inventory Reconciliation Sheet) <br />List dates tank #, and amount for all variations that exceeded the <br />allowable limits. <br />Date Tank # Amount <br />2. <br />3. .--zoo � <br />4. <br />5.. ,..,(�_ <br />Additional dates/amounts shall be continued on a separate sheet of <br />per 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 S,J.L.H.D. Environmental Health <br />Within 24 hours and an unauthorized release report submitted. <br />The quarterly sunswary report shall be submitted within 15 days of the end of each <br />quarter. <br />Quarter <br />1 <br />- January --> March <br />s: <br />Quarter <br />2 <br />- April --> June , <br />Quarter <br />3 <br />- July --> September <br />Quarter <br />4 <br />- October --> December <br />Send to: <br />SAN JOAQUIN LOCAL. HEALTH DISTRICT <br />1601 E. Hazelion, P.O. Box 2009 <br />e <br />Stockton, CA 95201 466-6781 <br />UGT 40 10/86 <br />J <br />c <br />4 <br />