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*NVENTORY RECONCILIATION <br />QUARTERLY SUMMARY REPORT FORM <br />facility Naa42a� QA1,C S41n j7OAA M aAL441 <br />facility Address: (:-C?1) A/. A41,q)pj <br />INS <br />oft <br />0 <br />V <br />1 hereby certify under penalty of perjury that all in r . 1) <br />the above mentioned facility were within the allowabl :Rt- L a t1h rs- <br />quarter. (No in Column 13 of the Inventory Reconciliation S Isom <br />L HF-ALTH <br />FNV1R01NMFMTA <br />Inventory variations exceeded.the allowable'limits for tWtC*1i9�y1CfS <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 the <br />Inventory Reconciliation sheet) <br />List tel tank #® and amount for all variations that exceeded the <br />allowable limits. <br />Date Tank # A.Mount <br />12- 2Q, I C3 <br />70. <br />3. In -a -m G As <br />4- 14)- t7- 9U 3 <br />5.. )]-c21-2p o). <br />• Additional dates/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 S . J . L . H . D . Environmental Health <br />Within 24 hours 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 I - January M * arch <br />Quarte * r 2 - April J * une <br />Quarter 3 - July September <br />Quarter 4 - October December <br />Send to: <br />UGT 40 10/86 <br />SAN JOAQUIN LOCAL HEALTH DISTRICT <br />1601 E. Hazelton, p.O. liox 2009 <br />Stockton, CA 95201 466-6781 <br />