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i <br /> i <br /> f gid;. INVENTORY RECONCILIATION <br /> QUARTERLY SUMMARY REPORT FORM <br /> rho Q tj IA- <br /> Facility Name:.�� �k�LJA,t-17DZ172_p(__ Tank <br /> Size Product <br /> ' Facility;Address; 317,30 <br /> DT- <br /> Telephone : <br /> LTTelephone : _7 ZZS <br /> Perso ling <br /> Report 4 -f- <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. (Ho in Cclu® 13 of the 1"vencory Reconciliation Sheet) <br /> 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) release. (Yes in Column 13 of the <br /> Inventory Reconciliation Sheet) _ <br /> List date, tank I, and amount for all variations that exceeded the <br /> allowable limits. <br /> Date Tank I Amount <br /> 1. RECEIVEV 2. <br /> 3. JUL 0 9 1990 <br /> 4. ENVIRONMENTAL HEALTH' <br /> PERMIT <br /> S. /SERVICES <br /> Additional dates/amounts shall be continued on a separate sheet of <br /> Paper and attached. <br /> I If the source of the variation which. exceeded allowable limits was due to <br /> a leak the incident shall be reported to <br /> within 24 hours and an unauthorized release reportl D bmittedonmental tical[h <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 I - July --> septemhcr <br /> Quarter 4 - October --> December <br /> Send to: SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E . Hazy I t fin . P .O. 11Ox 2000 <br /> Stockton , CA 95201 466-67b1 <br />*4 LILT 40 10/ 86 <br />