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IVENTORY RECONCILIATION <br /> QUARTERLY SUMMARY REPORT FORM <br /> M �✓� �12�CIz ( Tank# Size Product <br /> Facility Name: 30 _ � Iz� <br /> 1 � GAWI ISO D 4e� 2 <br /> Facility Address: q - Z <br /> Teleplx : !2 31 3 3 G <br /> person Filing <br /> Report: r z c-:> <br /> 0 I bareby certify under peaatty of Perjury that all inventory variations foe` ' <br /> the above oeaciosed facility were within the allowable limits for this JAN <br /> quarter. (Ho In Colum 12of the Inventory Reconciliation Sheet) FtiV;RGVNrT4LHEALTH <br /> y PERMIT/SERVICES <br /> V <br /> 13 Inventory vactatibas eaceadad the allowable that tthe tsource tfor the cvariation <br /> baceby certify under panalty of perjury <br /> vas not due to am unauthorizad (leak) release. (Yes in column 13 of the <br /> Inventory pecoaciliatioa Sheer) <br /> e all variations that exceeded the <br /> List dates tank Is sad amount foI <br /> allowable limits- Amount <br /> Date Tank M <br /> 2 20 t Z9 <br /> 3 . (. -� t 7 - <br /> 4 . <br /> 5. 2ZZ '7 4- <br /> 6, <br /> Z5 - c <br /> --- t/0Z/8. <br /> —78 <br /> 9. ?,d ZS_ /oL /-6,9 <br /> 10. '- 844 <br /> 11. / ZZ <br /> 12. t 57a <br /> 13. <br /> 14. koV_9 /fii <br /> 15.�- -3-- ! - / 7 � <br /> 16. !Z_ fzoh / - / frk <br /> 17. Z/ - Z4 # / G5 / - / Z� <br /> 18.x_ <br /> 19. <br /> 20. mac.. F _ /� -L + I75 <br /> 21.x_ <br /> 22.x— ?f 1 -L75 / t <br /> 23. / e -41 . l7 <br /> 24. o <br /> 25x_ t C <br /> 26:____i_:-(, �' Z - �! <br /> 7 <br /> 28. / 5 '/6 <br /> 29. 16 <br /> 30. o k 3 <br /> fi <br /> 31.Z� �- <br /> AAditioaal dates/amounts shall be continued on a separate sheet of <br /> paper and attached. <br /> If the source of the variation which. exceeded al'lowableElim`ts was duecto <br /> a leak the incident shall be reported to S.J .L.H.D. <br /> lth <br /> within 24 hours and an unauthorized release report submitted. <br /> _� -tiz �.4a nE each <br /> - IMquarterly summary report shall he submitted within =r= - <br /> quarter. <br /> Quarter 1 - January March <br /> Quarter 2 - April June <br /> Quarter 7 - July Septemhcr <br /> Quarter 4 - October --> December <br /> lead to: SAN JOAQUIN LOCAL HEALTH D15'l'HiCT <br /> 1601 E. Ilazc I t:u: , 11 .0 . 11ox 2009 <br /> . Stockton , CA 95201 466-6761 <br /> ;T 40 10186 <br />