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ep Go PL--n)tqu <br />INVENTORY RECONCILIATION ?I OCT 0 <br />QUARTERLY SUMMARY REPORT FORM <br />ENVIROMENTAL HEALTH <br />Facility Ham:2► ti 1 ll �P 3 1 <br />Facility Address: 3St4, gec�tAA- i <br />L�roi r C� �i "2�ro <br />Telephone: 1—U) -3 .-`l-1!7 <br />Person Filing <br />Reportt� P� <br />Tank <br />Size <br />-W 0AU40" <br />Product <br />Lt <br />Lcnn,o <br />5 <br />ILN <br />El1 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) releise. (Yes in Column 13 of the <br />Inventory Reconciliation Sheet) <br />Gist date, tank 1, and amount for all variations that exceeded the <br />allowable limits_ <br />Date Tank f Amount <br />2. <br />3. <br />4. <br />5. <br />Additional dates/amouats 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 11c3ith <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 1 - January March <br />Quarter- April --> June <br />Quarter ] - July --> Septcmh(!r <br />QQjarter - October --> lkcember <br />Send to: SAN JOAQUIN LOCAL HEALTH DISTRICT <br />160L E. llaze 1 lr+n , P.O. Box 2009 <br />Stockton, CA 95201 466-6781 <br />Ur1' 40 10/86 <br />