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v- G VU <br />acility Name <br />'acility Address: 07( <br />elephone: 94_]2__ <br />erson, Filln <br />eport:. <br />1�NVENTORY RECONCILIATION <br />ppQUARTERLY SUMMARY REPORT FORM <br />Tank # <br />W <br />Size <br />I hereby certify under penalty of perjury that all inventory variations <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 />Inventory variations exceeded the allowable limits for this quarter. 7 <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 />1. - ( C1 —(did-- — -- - ( -11� 9 6C�LIIt4t 'div G� <br />2. <br />3. <br />s <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) hoµrs and an unauthorized release report submitted. <br />.e gtiartgrly summary report shall be submitted within fifteen (15) days <br />the end of each quarter. <br />.I <br />Quarter 1 - January ---------- >March <br />Quarter 2 - April ------------ >June R2991913VQuarter 3 - July------------->Septem � <br />Quarter 4 - October ---------- >DecemberAPR 1 � 1992 <br />5 V <br />nd to: SAN JOAQUIN LOCAL HEALTH DISTRICT <br />1601 B. Hazelton, P.O. Box 2009 PERES()E41JFI <br />Stockfion, CA 95201 468-3420 „ <br />23 019 10/86 <br />