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INVENTORY RECONCILIATION <br /> QUARTERLY SUMMARY REPORT FORM <br /> Facility Name: _Z2V- Y D/ 7-C,/1A' Tank f <br /> Size Product <br /> Facility•Address: 7iuo D /�s 7� U� `$ rottry <br /> Telephone : <br /> Person Filing <br /> Report �� /t7LL R d/' <br /> 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 /> ❑ Inventory variations exceeded the allowable limits for tbi■ quarter. I <br /> hereby certify under penalty of perjury that the source for the variation <br /> "am not due to as unauthorized (leak) rel"se. (Yes is Column 13 of the <br /> Inventory Reconciliation Sheet) <br /> List date, tank f, and amount for all variations that exceeded the <br /> allowable limits. <br /> Date Tank f Amount <br /> 1. <br /> 3. OCT 5 1988 <br /> 4. ENVIRONMENTAL MIALTH <br /> 5. PERMIT 1 SERVICES <br /> Additional dates/amounts shall be continued an a separate sheet of <br /> Paper and attached. <br /> If the source of the variation whichexceeded allowable limits was due to <br /> • leak the incident shall be reported to <br /> Within 24 hours and an unauthorised release report sDubmeccedontal Health <br /> The Quarterly summary report shall be submitted within 15 days of the end of each <br /> Quarter. <br /> Quarter I - January --) March <br /> Qua 2 - April --)• Junc <br /> a rter ) - July --> Septclmhcr <br /> Quarter 4 - October --) lkcember <br /> Send to: SAN JOAQUIN 1.0CA1, HEAL7'1i DISTRICT <br /> 1601 E. I:azt• l t nn , P .O . ISox 2009 <br /> ;1' 40 IO/tib Stockton , CA 95201 466 -67b1 <br />