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t <br /> sT <br /> INVENTORY RECONCILIATION l?/o <br /> QUARTERLY SUMMARY REPORT FORM <br /> Facititr Name: >l=�L/� S �aG v/Y L SUS <br /> ✓V1-.1V1 l//Y/ -- Tank f Size. Product <br /> Facility:Address: ¢Lt <br /> 0 <br /> is = <br /> �,,,_.s'��'U o ad s U� <br /> Telephone : �p � ,���p- ��� � , <br /> Person Filing <br /> Report 0 HA <br /> ® 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 /> QInventory 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 unauthorised (leak) releise. (Yes in Column 13 of the <br /> Inventory Reconciliation Sheet) <br /> List date, tank 1, and amount for all variations that exceeded the <br /> allowable limits_ <br /> 1. <br /> Date Tank I Amount RECEIVED <br /> 2. J U N 2 6 1990 <br /> 3• ENVIRONMENTAL HEALTH <br /> 4. PERMIT/SERVICES <br /> 5. <br /> Additional dates/amounts shall be continued on a separate sheet of <br /> paper and attached. <br /> If the source of the variation which. cxceeded 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 /> Inc quarterly summary report shall be submitted within 15 days of the end of each <br /> quarter. <br /> Quarter I - January --) March Q�0 <br /> Qlartcr 2 - April --> June <br /> Quarter 3 - July --> Scptcmbi:r <br /> Quarter 4 - october --> DLcember <br /> Send to: SAN JOAQU IN LOCAL HEALTH DISTRICT <br /> 1601 E . Ha-r_c 1 l cin , P . O . Box 2009 <br /> SLockton , CA -X15201 466-6781 <br /> LILT 40 10/ 86 <br />