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INVENTORY RECONCILIATION <br /> QUARTERLY SUMMARY REPORT FORM <br /> Facility Name: r Tank # Size Product <br /> Facility Address: 6C /1,10 CCCD Lt's-k lei of <br /> tl 9 ev <br /> Telephone: <br /> Person, Filing <br /> Report: L� <br /> I hereby certify under penalty of perjury that -all inventory variation: <br /> for the above mentioned facility were within the allowable limits for <br /> this quarter. (No in Column 13 of the Inventory Reconciliation Sheet. ; <br /> a Inventory variations exceeded the allowable limits for this quarter. ] <br /> hereby certify under penalty of perjury that the source for the varia- <br /> tion was not due to unauthorized ( leak) release. (Yes in Column 13 of <br /> the Inventory Reconciliation Sheet ) . <br /> List date, tank # , and amount for all variations that exceeded <br /> the allowable limits . <br /> Date Tank # Amount <br /> It.0 76.?! — 8' <br /> 2. —�—� � Gam( X � -5 (o ; r <br /> 3. <br /> 4 . <br /> 5. <br /> Additional dates/amounts shall be continued on a separate sheet <br /> paper and attached. <br /> If the source of the variation which exceeded allowable limits was <br /> due to a leak, the incident shall be reported to San Joaquin Local <br /> Health District; Environmental Health Division, within twenty-four <br /> (24 ) hours and an unauthorized release report submitted. <br /> The quarterly summary report shall be submitted within fifteen (15 ) days <br /> of the end of each quarter. <br /> ruarter 1 - January---------->March <br /> Quarter 2 - April------------=>June <br /> Quarter 3 - July------------->September <br /> Quarter 4 - October---------->December <br /> >cnd to: SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 B. Hazelton, P.O. Box 2009 <br /> Stockton, CA 95201 468-3420 , <br /> R <br /> ,Il 23 019 10/86 <br />