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INVENTORY RECONCILIATION <br /> 1: •A3 <br /> QUARTERLY SUMMARY REPORT FORM <br /> Facility Name; �i6, 14till-,/ c'^� <br /> .t''�T2c�t._ Tank Size <br /> 51 ( Product <br /> F:cilit Address.- <br />;r9 y <br /> —: 4 aso ane <br /> Telephone : C{149 — -7 <br /> Z© <br /> Person Filing-i-, /l <br /> Report _ n (TI(w <br /> ArI hereby certify under Penalty f <br />� y operjury that all inventory variations for <br /> the above mentioned facility were within the allowable limits for this <br /> quarter. (No is Column l3 of the Inventory Reconciliation Sheet) <br /> i <br /> ❑ Inventory variations exceeded the allowable limits for this quarter. I <br /> hereby certify under penalty of perjury <br /> that the source for the variation <br /> was not due to an unauthorized (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 /> G allowable lionits. <br /> APIR 1 2 ��„`� <br /> Date Tank I AIR <br /> ITAL KALI <br /> 2. <br /> 3. <br /> 4. <br /> S. <br /> 1, Additional dates/amounts shall be continued on separate sheet of <br /> h <br /> a Darter and ?ttached. <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. Eevironmental Health <br /> within 24 hours and an unauthorized release report submitted. <br /> a <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 --) December <br /> Send to: SAN JOAQU IN LOCAL HEALTH DISTRICT <br /> 1601 E. Hazelton . P .O . 11OX 2009 <br /> Ut,T 40 10/86 Stockton . CA 95201 466-6781 <br />