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• i <br /> INVENTORY RECONCILIATION <br /> QUARTERLY SUMMARY REPORT FORM <br /> Facility Name: 4CiAL 1 � Tank # Size Product <br /> a'SiN- <br /> Facility Address: �(h�l (✓�n an1� P <br /> TV(Ac" <br /> Telephone : -1jc7�;56=0S7D <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 /> ElInventory 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 1, and amount for all variations that exceeded the <br /> allowable limits. <br /> ite :au;, ! orn.. <br /> 2. <br /> 3. <br /> 4. ENVIR <br /> UME: T <br /> S. FEnr.rt„ ,5. AL HEALTH <br /> 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 t'� <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 /> �y Qaar-te - January --> March <br /> D Quarter 2) - April --> June <br /> Quarter 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 /> Stockton , CA 95201 466-6781 <br /> UGT 40 10/86 <br />