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r� <br /> Past <br /> Q <br /> INVENTORY RECONCILIATION <br /> QUARTERLY SUMMARY REPORT FORM <br /> Facility Name: <br /> o J�/ <br /> Tank i <br /> Size ProductRHYiiON?E: 123 <br /> _5717Pacility Address: 28 ' <br /> EAST Y(lAil'E;aLm <br /> Telephone : <br /> Person Filin -- <br /> Report D V <br /> I hereby certify under penalty of perjury that all inventory variations for <br /> the above s+cationed facility Ne.-.e within the allowable limits for this <br /> quarter. (Ho in Column 13 of the Inventory Reconciliation Sheet) <br /> ar/Inventory variations exceeded the allowable limits for this quarter. I <br /> S o'AIjWcreby certify under penalty or perjury that the source for the variation <br /> r �ttw� not due to an unauthorized (leak) release. (Yes in Column 13 of the <br /> ventory Reconciliation Sheet) <br /> c,/x- v '041 List date, tank 09 and aawunt for all variations that exceeded the <br /> llovable limits. <br /> !✓ �Daatte{ _C Tank / Amount <br /> iffy 2: <br /> 3 <br /> 4. <br /> fdditiooal dates%amounts shall be continued on a separate <br /> paper and attached. �4m1 - <br /> 1y fi TT 7 <br /> It the source of the variation which exceeded allowable limits w�s d�CCo�� 13 1* <br /> A. leak the incident shall be reported to S ..3 . L. H . D. Environmental. Ilea lth <br /> within 24 hours and an unauthorized release report submitted. SNPI JONQUIII COUNOISTRICI <br /> POLUTION CONTRO <br /> The quarterly sun ry report shall be submitted within 15 days of the Acnd oLf each <br /> quarter• <br /> Quarter I - January --) March ^ <br /> Qjarter 2 - April --) June <br /> Quarter 7 - July --) .September <br /> Q.arter 4 - October --) zkcemher <br /> Send to: SAN JOAQUIN LOCAL HEALTH DIS lRIGI <br /> 1601 K . Htlzc- Ji (m , I' .o r„x )00') Q �I <br /> StockLori . CA 9i201 4()i, -67b1 J2 <br /> U(;'l, 40 10! 81) / T <br /> / D� � � �r4 <br />