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INVENTORY RECONCILIATION APR 17 1989 <br />QUARTERLY SUMMARY REPORT FORM <br />r i,rh(`°Ii <br />,:�r��rvr1 Hc- r� <br />Facility Name: <br />Facility Address: QSq S -Jtoe� �- <br />7��-.,. <br />Telephone: 204 S <br />Person Fi ng <br />Report <br />Tank i ' `5'ikh"`v1-- Product <br />O -o b <br />0-O 0 <br />13-4 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 />E] 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 />List dates tank i, and amount for all variations that exceeded the <br />allowable limits. <br />Date Tank It Amount <br />2. <br />3. <br />4. <br />5. <br />Additional dates/amounts shall be continued oa a separate sheet of <br />paper and attached. <br />If the source of the variation whichexceeded 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 --> March <br />Quarter 2 - April --> June <br />Quarter 3 - July September <br />Quarter 4 - October --> December <br />Send to: SAN JOAQUIN LOCAL HEALTH DISTRICT <br />1601 E. f.azeILoll , 1'.0. Box 2009 <br />Stockton, CA 95201 466-6761 <br />UCT 40 10/86 <br />