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rA TO <br /> Vi 419x9 , <br /> INVENTORY RECONCILIATION RpMEl0�AE0 <br /> 0 <br /> QUARTERLY SUMMARY REPORT FORM EyvFGRMIfI <br /> Facility Name r��9r-Z-)� .1.{;.�'l Z- /CE Tank / Size Product <br /> Facility Address: ,7r70/ <br /> Telephone : 4)2—VZ3 <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 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 i, and amount for all variations that exceeded the <br /> allowable limits. <br /> Date Tank R Amount <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 IieaIth <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 <br /> uarter. Quarter I - January --> March <br /> Quarter 2 - Apri wle <br /> Quarter 3 - July --> 5eprember <br /> Quarter 4 - October --> li,cember <br /> Send to: SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E . Hazel ( on . P . 0 . hox 2009 <br /> Stockton , CA 95201 466 -6781 <br /> U(;T 40 10/ 86 <br />