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0 ! <br /> INVENTORY RECONCILIATION <br /> QUARTERLY SUMMARY REPORT FORM <br /> Facility Name: L a 11 D d`'C r-- Tank i Size Product <br /> P, -7 Y,6,0 0 S" <br /> Facility Address: S G sr 1't4 '54 c4 r <br /> c 0753 U D L <br /> Telephone : '.2C y - I? S k - Y7o <br /> Person Filing <br /> Report ,f a rPA 12 5 0q , L ail c <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_ (Ho in Column 13of 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 cot due to an unauthorized (leak) release. (Yes in Column 13 of the <br /> Inventory Reconciliation Sheet) <br /> List date, tank #, and amount for all variations that exce'9ded the <br /> allowable limits. , <br /> Date Tank £ Amount <br /> .rAt••9. (.a <br /> 2. <br /> 3. v <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 --> .lune <br /> Quarter 3 - July --? September <br /> Quarter 4 - October --> December <br /> Send to: SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E . Naze 1 c_m« , P . 0 . BOx 2009 <br /> SCockton , CA 95201 466-6781 <br /> UCT 40 10/86 <br />