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a <br />INVENTORY RECONCILIATION <br />QUARTERLY SUMMARY REPORT FORM <br />Facility Name; --Z70'11A'L <br />Facility Address: 12�,7✓` !!2� •I/�//y1 <br />�rt�'t� rs-,ieJ <br />Telephone: `7 <br />Person Filing <br />Report <br />fa �� <br />vu <br />JAN 2 3 1992 <br />ENVIRONMENTAL H -d,!- T;.' <br />nconniT JCCkV1r..FF % <br />Tank / Size Product <br />o <br />4eQu� Vws <br />Z G oco Nc <br />o � . v•L <br />r�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 />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) 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 limits. <br />Date Tank # Amount <br />2. <br />3. <br />4. <br />S. <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 #hall 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 day* of the end of each <br />quarter. <br />Quarter I - January March <br />Quarter 2 - April --> June <br />Qua - Jul -a) September <br />Quarter 4 October --> Dece S <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 />