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Facility Name: <br />129 <br />q/ �'o J <br />INVENTORY RECONCILIATION ,!'IH <br />QUARTERLY SUMMARY REPORT FORM s" '°w"; <br />La <br />facility Address: 23b fl. "AM L ---i <br />L o u4 G cs "15 -1-4,0 <br />Telephone: -Z o°1 '554- 21-`i 1 <br />Person Filing <br />Report <br />Tank i Size <br />Product <br />$ b 'W C <br />G�sal�rp <br />Z t o o• o <br />s.._. �.x.v..a <br />+4 o,a v <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 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 I Amount <br />I 2. <br />�90 <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 su=aary report shall be submitted within 15 days of the end of each <br />quarter. <br />Quarter I - January --> Harch <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. Hazelton. P.O. Boy: 2009 <br />Stockton, CA 95201 466-6781 <br />UCT 40 10/86 <br />'\ *W <br />