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� Jud <br />p� 8 & 0, <br />INVENTORY RECONCILIATION ��ME�ySA�'�"��5,� <br />Cj QUARTERLY SUMMARY REPORT FORM �N YVRMSER����s <br />Facility Names\�/y//��i�G <br />Facility Address; <br />Telephone: el <br />Person Filing L <br />Report <br />Tank f <br />/61 <br />Sire <br />Product <br />21z - <br />1L �ZPM <br />Z- <br />c m�e <br />UNGE�IJ <br />L�1 I hereby Cgrfify under penalty of perjury that all. inventory variations for <br />/� the above areationed facility were within the allowable limits for this <br />ivar:er.(Mn _ !.12- a haF rl; Inventory Reconciliation Sheet) <br />Q Inventory variations exceeded the allowable limits for this quarter. I <br />hereby certify under penalty of perjury that the source for the variation <br />W44 not due to an unauthorized (leak) release. (Yes in Column 13 of the <br />Inventory Reconciliation Sheet) <br />List date, tank f, and amount for all variations that exceeded the <br />allowable lis•ita. <br />Date Tank i Amount <br />I- <br />2. <br />3. <br />4. <br />5. <br />Additional dates/amouots shall be continued on a separate sheet of <br />paper and atcacbed. <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 1 - January --> Harch <br />Quarter 2 - Ap --> June <br />— 34arrer 3 - July -) Septem er <br />Quarter 4 - October --> December <br />Send to: SAN JOAQUIN LOCAL HEALTH DISTRICT <br />1601 E. Hazelton, P.O. Box 2009 <br />Stockton, CA 95201 466-6781 <br />UGT 40 10/86 <br />