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INVENTORY RECONCILIATION <br />QUARTERLY SUMMARY REPORT FORM <br />Facility Name: O)Lcom.h C4\6vr0f'1 <br />Facility Address: 3'0I W��,,,�N [� <br />Loo, rA r-rSaUO <br />Telephone: `2" 368--e&q <br />Person Filing_ j.44 <br />Report �' e <br />Tank E Size Product <br />�. 4 C <br />L <br />�I 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 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 to an unauthorized (leak) release. (Yes in Column 13 of the <br />Inventory Reconciliation Sheet) <br />List date, tank 1, and amount for all variations that exceeded the <br />allowable limits. I <br />C �nn <br />Date Tank E Amount <br />® �O <br />1. l A N 1 <br />ENVIROMENTAL HEALTH <br />FERMIT/SERVICES, <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 --) March <br />Quarter 2 - April --> June <br />Quarter 3 - July --> September <br />Quarter 4 - October --) (),cember <br />Send to: SAN JOAQU I. 4 LOCAL HEALTH DISTRICT <br />1601 i'.. Haze 1 (()n . P .O . 1iox 2009 <br />SLockton. CA 95201 466-67b1 <br />Ur.T 40 10/86 <br />