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INVENTORY RECONCILIATION <br /> QUARTERLY SUMMARY REPORT FORM <br /> Facility Name: �A OJ J rO Tank i Size Product <br /> Facility Address: c20 UO .S CAC <br /> G Ti7iG Z_ �,;✓T,C4 47t2e, <br /> Telephone : <br /> Person Filing <br /> Report /-7, <br /> I hereby certify under penalty of perjury that all inventory variations for <br /> the above mentioned facility were :.ithin 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) release. (Yes in Column 13 of the <br /> Inventory Reconciliation Sheet) <br /> List date, tank f, and amount for all variations that exceeded the <br /> allowable limits. <br /> Date Tank f Amount <br /> 1. <br /> 2. <br /> 3. <br /> 4. <br /> 5. <br /> Additional dates/amounts shall be continued on 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 Hcalrh <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 /> darter 2 - April --> June <br /> Quarter-3 - u y------->-S—eZ ember <br /> Quarter 4 - October --> December <br /> Send to: SAN JOAQUIN LOCAL HEALTHDIS'1'I2IC'f <br /> 1601 E . Hazelton , P .O . Box 2009 `�d J <br /> DEI; <br /> Stockton , CA 95201 466-67b1 <br /> UCT 40 10/86 ENVIROMETAL HEALTH <br /> PERMIT/SERVICcS <br />