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INVENTORY RECONCILIATION <br />QUARTERLY SUMMARY REPORT FORM <br />Facility Haze: /"( ' 'l4-1, �'yXA <br />lacility Address: f` 9;`r �t, 4�1 j�f i� <br />Telephone: (,_ <br />Person Fili,7g <br />Report <br />TA Size <br />Product <br />r <br />L hereby certify under penalty of perjury that all inventory variations for <br />the above mentioned facility were vithin the allowable limits for this <br />quarter. (No in Column D of the Inventory Reconciliation Sheet) <br />ElInventory variations exceeded the allowable limit* for this quarter. I <br />hereby certify under penalty of perjury that the -ce for the variation <br />was not due to an unauthorized (leak) releise. (" 1 Column 13 of the <br />Inventory Reconciliation Sheet) <br />I <br />List date, tank 0, and amount for all varia�'-;ns chat exceeded the <br />allowable limits. <br />Date Tank f Amount <br />Z. <br />]. <br />4. <br />5. <br />Additional dates/amounts shall be continued —1 a separate sheet of <br />paper and attached. <br />If the source of the variation which exceeded aIle. ble limits was due to <br />a leak the incident shall be reported to S.J.L.I! [) 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 I - January --) march <br />Quarter 2 - April --> JUI%4! <br />Quarter ) - July --) Septemher <br />Q%Jarter 4 - October --) Qecrmber <br />Send to: SAN JOAQU IN LOCAL HEAL -1-1i DI ` TIe I CT <br />1601 F:. Ha;'C I t (M . P.O. 1iox ).. W'') <br />Stockton, CA 95201 466-61b <br />1' 40 10/86 <br />V <br />NT AL HEALTH <br />EN E1ERM►T/SERVICES <br />