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,INVENTORY RECONCILIATION <br />QUARTERLY SUMMARY REPORT FORM <br />Facility Name: LA <br />Facility Address: . <br />Telephone: Z 0°1 4— ?-4 ► <br />Person Filing <br />Report Ke -v-1 1 A 19 e <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 # Amount <br />1. '. , 7 <br />2. <br />m <br />3. JAN 2 5 lflfl <br />4. ENV1R01 1',\1_,TAs HEALTH <br />5. PERM /SLRV1 E -S <br />Additional dates/a=ouats shall be continued on a separate sheet of - <br />paper <br />fpaper 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 />Qaarter 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. Boa: 2009 <br />Stockton, CA 95201 466-6781 <br />UCT 40 10/86 <br />RM <br />�3".-MgX <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 # Amount <br />1. '. , 7 <br />2. <br />m <br />3. JAN 2 5 lflfl <br />4. ENV1R01 1',\1_,TAs HEALTH <br />5. PERM /SLRV1 E -S <br />Additional dates/a=ouats shall be continued on a separate sheet of - <br />paper <br />fpaper 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 />Qaarter 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. Boa: 2009 <br />Stockton, CA 95201 466-6781 <br />UCT 40 10/86 <br />RM <br />