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INVENTORY RECONCILIATION <br /> QUARTERLY SUMMARY REPORT FORM <br /> Facility Name: AjQ/7/7,�/ 7TL7he� /l=eH1. Tank I Size Product <br /> C'a _ E <br /> Facility4ddress: aQ.�� GU fTAts'�Tdt� >iL G <br /> STlcsCTaJ t^A <br /> Telephone : g66 - 37/.S <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 /> QInventory 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 /> Dale Tank / Amouoc1. <br /> 2. APR b 1018 <br /> 3. EWRUMENTAL HEALTH <br /> 4_ FERMIT/SERVICES, <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 which. cxcecdcd allowable LiuiCs 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 /> artcr 1 - January --) March 1969 <br /> Quarter 2 - April -- June <br /> Quarter ) - July --> Septemher <br /> Quarter 4 - October --> Deccmber ...... <br /> Send co: SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. IlazeI1n11 , P .O. Ncxat.2009 <br /> Stockton , CA 95201 466-67bl <br /> UCT 40 LO/rib <br />