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rl <br />,�Ll— <br />#' <br />4UARTERLYSUMMARY REPORT O, <br />Facility Name: <br />Fac. ity Address: 7.;2 <br />Telephone: <br />Person Fil'� <br />Report <br />2 <br />,-T$ , r �( <br />® I hereby certify under penalty of perjury that all inventory variations <br />the above mentioned facility were within the allowable limits for this for <br />quarter. (No in Column 13of 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 CO an unauthorized (leak) release. (Yes in Column 13 of the <br />Inventory Reconciliation Sheet) _ <br />List date, tack i, and amount for all variations that exceeded the <br />allowable limits. <br />Date Tank Amount <br />3. g - `i 0 <br />G. (,A 3c, <br />r :.k <br />5. 1g. 9C) 'P _ iI"7 <br />t a.. - Of --7 o ' 9 <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 <br />quarter, IS days of the end of each <br />Quarter I - January March <br />Q'1arter 2 - April __> June <br />Quarter 3 - July --> September <br />Qe,arter 4 - October --> December <br />Send co: SAN JOAQUIN LOCAL HEALTH DISTRICT <br />1601 E. Hazelton, P.O. Box 2009 <br />UCT 40 10/86 Stockton, CA 95201 466-6781 <br />