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INVENTORY RECONCILIATION <br /> QUARTERLY SUMMARY REPORT FORM <br /> Facility Name: ,.�s Re,r-_/__ Z-,,,_ Tank t Size Product <br /> Facility Address: -P.t 4 911, <br /> G'. C r a <br /> Telephone : d % <br /> Person Filin <br /> Report a <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 /> 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 Coltmm 13 of the <br /> Inventory Reconciliation Sheet) <br /> List date, tank #, and amount for all variations that exceeded the <br /> allowable limits. <br /> Date Tank # Amount <br /> 2. JUL 2 0 190081 <br /> 3. ENVIROMENTAL HEALTH <br /> 4. <br /> PERMIT/SERVICES <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 repos[ 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 --> .lune <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 /> UCT 40 10/86 <br />