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i • <br /> INVENTORY RECONCILIATION <br /> QUARTERLY SUMMARY REPORT FORM <br /> Facility Name: r hGs �,�or �S Tank fNiz; Product <br /> Facility Address: 16(,1!5 S,7 Sf PbBc�y� u rLei-lki-og2 el, �� <br /> Telephone : �OC� _ f{_ 2170 <br /> Person Filing / / <br /> Report Jt rn .S � /a `ra c y C7 <br /> E] I hereby certify under penalty of perjury that all inventory variations for <br /> the above mentioned facility were within the allowable limits RECEIVE <br /> quarter. (No in Column 13 of the Inventory Reconciliation She <br /> J U L 1 6 t�^� <br /> ® Inventory variations exceeded the allowable limits for this <br /> herebycertify under Eth -V 1Zr�,gnc�,VHEALTH <br /> y penalty of perjury that the source for th Lv �1fi` ,CttV(CES <br /> vas not due to an unauthorized (leak) release. (Yes in Column IT' 1h �Ctt <br /> Inventory Reconciliation Sheet) <br /> List date, tank i, and amount for all variations that exceeded the <br /> allowable limits. <br /> Date Tank I Amount <br /> Tank efnpfl¢d June IS_ <br /> 2. <br /> 3. <br /> 4- R¢�ar�irlq �orrN S¢h � o gout <br /> 5. ofF;�� Qo <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 allowabie limits vas due [o <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 /> Quarter 3 - July September <br /> Quarter 4 - October --) December <br /> Send to: SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E . Ilazelt.on , P .O . Box 2009 <br /> Stockton , CA 95201 466-6781 <br /> UCT 40 10/ 86 <br />