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M ° <br /> fiv <br /> INVENTORY RECONCILIATION JAN <br /> QUARTERLY SUMMARY REPORT FORM ENViRC•NNIENTt't <br /> Facility Name: 0Z, ooffytY\C(LWN( ,UA(l�- Tank / Size. Product <br /> 777 77 <br /> FacilityWdress: tpL!�S0 L�Nr6�z C-Q <br /> Telephone : UCS) `3L, OE-� c <br /> Person Filinl�- <br /> ReportJ�O <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. (Ho in Column 13 of the Inventory Reconciliation Sheet) <br /> ElInventory variations exceeded the allowable Limits for this quarter. Z <br /> hereby certify under penalty of perjury that the source for the variation <br /> was not due to as unauthorized (leak) releise. (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 It Amount <br /> 1. <br /> 2. <br /> 3. <br /> 4. <br /> S. <br /> AdditioaaL dates/amounts shall be continued on a separate sheet of <br /> paper and attached. <br /> If the source of the variation which. esceeded allowable limits 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 /> Quarter I - January --> March <br /> Quarter 2 - April --) June <br /> Quarter 3 - JULY Septemher <br /> Quarter 4 - October --) December <br /> Send to: SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 160L E . Hazelton , P . O . Rox 1009 <br /> Stockton , CA 95201 466 -67bl <br /> IICT 40 10/ 86 <br />