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0 0 <br />INVENTORY RECONCILIATION <br />QUARTERLY SUMMARY REPORT FORM <br />Facility Name: <br />Facility Address: _/7075 g=—• W,,p-W ,1 ST <br />Telephone : <br />Person Fili <br />Report _(`f/C�io <br />Tank ! Size <br />Product <br />C o00 <br />/2EC•T <br />u 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 Column 13of the Inventory Reconciliation Sheet) <br />ElInventory 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 Column 13 of the <br />Inventory Reconciliation Sheet) <br />List date, tank /, and amount for 21L variations that exceeded the <br />allowable Limits. <br />Date Tank I Amount <br />2. 4- <br />3. <br />4. <br />5. <br />vVIkO,(VL11AL HEALTH <br />Additional dates/amounts shall be continued on a separate sheet of <br />paper and attached. <br />If the source of the variation whichexceeded allowable limits vas due to <br />a leak the incident shall be reported to S.J.L.Ii. D. Environmental 11caich <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 />Qaarter 2 - April --) June <br />Quarter 3 - July --) ScpCcmbcr <br />Q"arter 4 - October --) ll.rcember <br />send co: SAN .JOAQUIN LOCAL HEALTH DIS'IRICf <br />1601 E. Hazollnn, P.O. h')X 2nW1 <br />SLockton. CA 95201 466-67bl <br />0(;T 1.0 10/80 <br />