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gj <br /> .. '1-J <br /> 1 <br /> INVENTORY RECONCILIATION JAN 9 11,111-1 <br /> QUARTERLY SUMMARY REPORT FORM ENVIRONMENTAL. HEALTH <br /> 1 ;-'s <br /> PERM!T/SLRVI k.11,V- <br /> Facility Name: L a 4r r- o Tank f Size Product <br /> 9 P-0 , e Y. IF 7 000 <br /> Facility Address: -7 -'g 5-L de) 0 <br /> I- 4-A f-& 3 3-6 Ug PC a OL-d q cc/a <br /> Telephone : <br /> 7 0 <br /> Person Fil <br /> ReporL <br /> V <br /> 1 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 this quarter. I <br /> hereby certify under penalty of perjury that the source for the variation <br /> was not due to an unauthorized (leak) relea' se. (Yes in Column 13 of the <br /> Inventory Reconciliation Sheet) <br /> List date, tank 1, and amount for all variations that exceeded the <br /> allowable limits. <br /> Date Tank I Amount <br /> 1. <br /> 2- <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 /> Quarter 3 - July September <br /> Quarter 4 - October Dc-cember <br /> Send to: SAN JOAQUIN LOCAI, HEALTH DISTRICT <br /> 1601 K . haze lt-()') , P . O . Box 2009 <br /> SLockLon , CA 95201 466 -6781 <br /> t%T 40 10186 <br />