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INVENTORY RECONCILIATION <br /> T /QUARTERLY SUMMARY REPORT FORK <br /> Facility Names 1 l,lo(Y mf(C�L=:S] \, Tank Size Product <br /> Pacility4ddress: (OZAb (-A"W', 20, <br /> QaC4 esa. <br /> Telephone : �Q 83Lo {�g7v <br /> Person Fili <br /> Report 2��3p u)''i �6SCL� <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 /> E] 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 to Column 13 of the <br /> Inventory Reconciliation Sheet) <br /> List date, tank 1, and amount for all variations that exceeded the <br /> allowable limits. <br /> Date Tank / Amount <br /> 2. r ,ASH <br /> 3. 0ERM1jtI5ER�K E' <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 which. exceeded 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 --) Harch <br /> Quarter 2 - April --> June <br /> darter_.3) - July --> September <br /> Quarter 4 - October --> December <br /> Send to: SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E . Hazelton , P . O . Box 2009 <br /> Scockton , CA 95201 466 -6781 <br /> LJGT 40 10/ 86 <br />