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INVENTORY RECONCILIATION <br /> e QUARTERLY SUMMARY REPORT FORM <br /> Facility Name: - -,9w�. - t Tank # Size Product <br /> Facility Address�L1 % QLO t� <br /> , "19 -GOS O-G-a <br /> Telephone : <br /> Person Fil • g <br /> Report P �L` , ����lb�a ✓ 0 1��� , <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 13of 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 in Column 13 of the <br /> Inventory Reconciliation Sheet) <br /> List date, tank it, and amount for all varixtigp • t{liti;gxgee-ed• Iy{�,e <br /> allowable limits. ��l ,1 li 1�' 11 fVw7f II,_•Ig <br /> Date rank # Amount JAN 191989 <br /> 1. <br /> ENViR01Q0ArNTAL HEALTH <br /> 2. PERMIT/SERVICES <br /> 3. <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 --> March <br /> Quarter 2 - April --> June <br /> artec 3 Jul --> Se [ember <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 />