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I ' d �d101 <br /> C j INVENTORY FECONCILIATIA <br /> QUARTERLY SUMMARY REPORT FORM <br /> Facility Name: /1F,?ic7./ sy✓i✓`s Tank # Size Product <br /> 41, <br /> io, oao V ogso <br /> Facility Address : <br /> Telephone: s - y a <br /> Person Filing <br /> Report : , oz�/ <br /> I hereby certify under penalty of perjury that all inventory variation: <br /> ❑ for the above mentioned facility were within the allowable limits for <br /> this quarter. (No in Column 13 of the Inventory Reconciliation Sheet. <br /> Inventory variations exceeded the allowable limits for this quarter. <br /> ❑ hereby certify under penalty of perjury that the source for the varia- <br /> tion was not due to unauthorized ( leak) release. (Yes in Column 13 of <br /> the Inventory Reconciliation Sheet ) . <br /> List date, tank # , and amount for all variations that exceeded <br /> the allowable limits . <br /> Date Tank # Amount <br /> 1 . „5 -�- P9 � G •f/•A <br /> 2 . 41-a-,'-9y �/ /•s" <br /> 4 . s/-?9 y G•/ <br /> 5 . <br /> Additional dates/amounts shall be continued on a separate sheet <br /> paper and attached. <br /> If the source or, the variation which exceeded allowable limits was <br /> due to a leak , the incident shall be reported to San Joaquin Local <br /> Health District; Environmental Health Division, within twenty-four <br /> ( 24 ) hours and an unauthorized release report submitted. <br /> The quarterly summary report shall be submitted within fifteen ( 15 ) days <br /> of the end of each quarter . <br /> Quarter 1 - January-------- >March <br /> 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.0. Box 2009 <br /> Stockton, CA 95201 468-3420 <br /> EH 23 019 10/86 <br />