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INVENTORY RECONCILIATION <br /> QUARTERLY SUMMARY REPORT FORM <br /> PaciLLCy Name: Qf Oy c �jU/��'�j1�,�/ Sank I Size Product <br /> PaeiliCy Add re u: G/ �el _ r <br /> TelephonePerson <br /> Report Fil <br /> Re /r /itc�� /.E"ei✓� <br /> P Iy <br /> El L 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 13of the Inventory Reconciliation Sheet) <br /> Er"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) releise. (Yes in Colum 13 of the <br /> Inventory Reconciliation Sheet) ' <br /> List date, tank f, and amount for all variations that exceeded the <br /> allowable limits. ffnnll <br /> Dace Tank /f Amount PD <br /> 1. OCT 141988 r <br /> �7J <br /> 2. g ENVIRON^i1G`JTAI. <br /> HEALTH <br /> 3. 1fff Z 7- PERMIT/SERVICES <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. excecded allowable limits was due to <br /> a leak the incident •hall be reported to S .J .L.H.D. Environmental Ucalth <br /> within 24 hours and an unauthorized release report submitted. <br /> The quarterly sum ary report shall be submitted within 15 days of the end of each <br /> quarter. <br /> Quarter I - January March <br /> Quarter 2 - Apd-L <br /> CQuarter 3 - Jul —> septcmher_. > <br /> Quarter 4 - October --> December <br /> Send co: SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. Hazelton , P .O . Box 1009 <br /> Stockton . CA 95201 466-6761 <br /> ICT 40 10/86 <br />