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INVENTORY RECONCILIATION <br /> QUARTERLY SUMMARY REPORT FORM <br /> Facility Name: d C�Tn Tank I Size Product <br /> /O v<� 1�cL4dfiJ <br /> Facility Address: 3Lf� r�2j'f 'ify� ? Z J dam" iJifSFc <br /> _ ' .. <br /> Telephone : 1711E5 -4 /1& <br /> Person Filing <br /> Report <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 13 of the Inventory Reconciliation Sheet) <br /> 0 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 /, and amount for all variations that exceeded the <br /> allowable limits. <br /> Date rank I Amount S30Ua3S/11W2133 <br /> H11V3H 1V.LN3NomN3 <br /> 11-715-E <br /> 2. i2 ti � � ?E, 4r _ 6! q Ndf <br /> 3. <br /> 4. <br /> 5. <br /> Additional dates/amounts shall be continued on a separate sheet of <br /> paper and attached. _ <br /> W , <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 --> (kcember <br /> Send to: SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 160L E. 11azc• 11on . P .O . Box 2009 <br /> SLockton . CA 95201 466-6761 <br /> UCT 40 10/86 <br />