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l5la <br /> INVENTORY RECONCILIATION � <br /> S <br /> QUARTERLY SUMMARY REPORT FORM AUC Z E i4p., <br /> Facility Name: Tank # S FNVIPor � _ uc <br /> �F�O� � �;ld <br /> e:�. <br /> Facility Address: /Q Y p o - <br /> OL.t�t ecg� CA. <br /> Telephone : <br /> Person Fil* <br /> Report �e2nti Pc�t6(Y <br /> E] 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 13 of 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 /> vas not due to an unauthorized (leak) release. (Yes in Column 13 of the <br /> Inventory Reconciliation Sheet) <br /> List date, tank #, and amount for all variations that exceeded the <br /> allowable limits. <br /> Date Tank # Amount <br /> a�( <br /> 3. � k �_ 3?-z- <br /> 4. <br /> 5.. �n1�j $a <br /> co-� � d 7L\ <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 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 IS days of the end of each <br /> quarter. <br /> Quarter I - January --> March <br /> Quarter 2 - April --> June <br /> Quarter 3 - July --> September <br /> Quarter 4 - October --> December <br /> Send to: SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E . llazelton , P . O . Box 2009 <br /> Stockton , CA 95201, 466-6781 <br /> UCT 40 10/86 <br />