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INVENTORY RECONCILIATION <br />QUARTERLY SUMMARY REPORT FORM <br />Facility Name: &V1 e4 q k S aA. <br />Facility' Address: l2 TV <br />Telephone: 3 (.1 <br />Person Filing <br />Report -e-v,k..1 145 8.y h1�C- <br />ET",`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 />F1Inventory 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) release. (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 />Date Tank f Amount <br />1. <br />2. <br />3. <br />4. <br />S. <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 IS days of the end of each <br />Quarter. <br />Quarter I - January March <br />Quarter 2 - April --> June <br />Quarter 3 - July --> September <br />Quarter 4 - October --> Ik:cember <br />Send to: SAN JOAQUIN LOCAL HEALTH DISTRICT <br />1601 E. Haze 1 t tin • P . 0 . Box 2009 <br />Stockton, CA 95201 466-6781 <br />IJc;T 40 10/86 <br />f PQ F'1 2 3 <br />HEALTH <br />PERMIT/'iE"vicEs <br />