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u <br />INVENTORY RECONCILIATION <br />QUARTERLY SUMMARY REPORT FORM <br />(i I <br />EN LIERrdlll /SERV CLS TH <br />Facility Name:�If <br />3 213 2 W. l-9iN�IM►ER LANE <br />Pacilit Address: T T n r, -T? 7, <+:: <br />Telephone: Q r�-7 Z,CCD <br />Person Filin <br />Report <br />Product <br />SAI <br />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 />El 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) releise. (Yes in Column 13 of the <br />Inventory Reconciliation Sheet) <br />List datev tank i, and amount for all variations that exceeded the <br />allowable limits. <br />Date Tank # Mount <br />2. <br />3. <br />4. <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.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 15 days of the end of each <br />Quarter. <br />Quarter I - January --> March <br />le Q octet 2 April --> June <br />Quarter 3 - July --> Scptcmht:r <br />Quarter 4 - October --> Ikcember <br />Send to: SAN JOAQUIN LOCAL HEAL1'li DISTRICT <br />1601 E. Haze 1 c0m , P.O. [lox 2009 <br />Stockton, CA 95201 466-6761 <br />UCT 40 10/86 <br />