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INVENTORY RECONCILIATION JUL l 1;189 <br /> QUARTERLY SUMMARY REPORT FORM <br /> if'ONMENi.AL H7:'.`. <br /> Facility Nasse: Lzi na 4-,,m`, ✓'C 0 Tank t Size Product <br /> r <br /> Facility Address: / 41 C5 7 IL 54- <br /> C'. GP7 ccffzi [ice. �e{ G13 (� CC) <br /> Telephone : <br /> Person Filing <br /> Report .� a �, �� i7. � nj <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 Colu=a 13 of the Inventory Reconciliation Sheet) <br /> QInventory 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 Colu=n13 of the <br /> Inventory Reconciliation Sheet) <br /> List date, tank #, and amount for all variations that exceeded the <br /> allowable limits. <br /> Date Tank I Amount <br /> 1. <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 sha11 be reported to S ,J .L .H . D . Env ironmenta L Hea 1 c <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 /> Q,sarter 2 - April --> ,lune <br /> Quarter 3 - July --> September <br /> Quarter 4 - October --> Dcce tuber <br /> Send to: SAN JOAQUI(N LOCAL HEALTH DISTRICT <br /> 1601 E . Haze 1 t.on , 1' . 0 . fico:: 2009 <br /> Stockton , CA 95201 460 -6781 <br /> UCT 40 10186 <br />