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INVENTORY RECONCILIATION <br /> QUARTERLY SUMMARY REPORT FORM <br /> Facility Name: ).r , G ��o(sl:- Tank I Size Product <br /> � It_- C'00 <br /> Facility Address: (6w E• 1Z tC Uc�O ('L aa' <br /> 14 <br /> Telephone : Noel ut'a- 12'o( <br /> Person Filing <br /> Report �-Xt W-A y <br /> ElI 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 /> EI/ 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 as unauthorized (leak) release. (Yes in Column 13 of the <br /> Inventory Reconciliation Sheet) <br /> List date, tank i, and amount for all variations that exceeded the <br /> allowable limits. <br /> Date Tank f Amount <br /> 1. • ,' _ < ia�� <br /> 2. <br /> 3. <br /> 4. <br /> 5. <br /> Additional dates/amount: shall be continued on a separate sheet of <br /> paper and attached. <br /> If the source of the variation vhich. 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 /> 1he quarterly summary report shall be submitted vithin 15 days of the end of each <br /> quarter. <br /> Quarter I - January March <br /> QQiarter 2 - April --> Juni <br /> Quarter 3 - July --) September <br /> - <( jarter 4 - October --) tk-cember 'b'l <br /> Send to: SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 160L E . P .O . [iOX 2009 <br /> SLockcon , CA 95201 466 -6781 <br /> 11t;T 40 10/ 86 <br />