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i OC4 eel r7lr <br /> INVENTORY RtCONCILIAPiON <br /> QUARTERLY SUMMARY REPORT FORM <br /> Facility Name: 0,4L1r6),,W014-_ZL Tank P' Size <br /> / �� C)� - — Product <br /> Facility Address: 3-3-3,0 - AGF <br /> J'Zoe <br /> Telephone : 7 -ZS, - <br /> Person ftiAng <br /> Report L <br /> I her by cert y under penalty of perjury that ;11 inventory variations for <br /> / the above mentioned facility were within the allowable licits for this <br /> quarter. (No in Column 13o tite Inventory Rcconciiiation 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 /> i <br /> List date, tank 1, and amount for all variations that exceeded the <br /> allowable limits_ <br /> Date Tank f Amount <br /> 3- FEB 23 fe l <br /> 4_ LNVIRONMENTAL HEALTH <br /> 5. PE°'M'iITlS ER Vi ' <br /> Additional dat+esjamounts shall be continued on a separate sheet of <br /> paper and attached. <br /> If the source of the variation which. exceeded at-lovable limits was .due to <br /> a leak the incident shall be reported to S .J .L. H . D. Environmental Health <br /> wLrhin 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 1 - January --) March <br /> QQjarter 2 - April --> June <br /> Quarter 3 - July --) sepcember <br /> Quactcr 4 - October---) -(kcember 1 <br /> I <br /> V <br /> Send to: SAN JOAQUIN LOCAL HEALTH D1STH ICT <br /> 1601 E . Haze l t (m . P . O . Flom mol) <br /> Stockton , CA 95201 466-67b1 <br /> UCT 40 10/86 <br /> i <br />