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INVENTORY RECONCILIATION <br />QUARTERLY SUMMARY REPORT FORM <br />Facility Name: _ 1),V �; /1V / M. <br />Tank size <br />Pcoduct <br />Facility Address: l'7/ ,y�y 00 U.UGzf1� <br />FIR <br />-"',6 f P <br />777 3 Cr <br />Telephone: ���-� <br />Person Filing <br />Report — <br />❑ 1 hereby certify under penalty of perjury that •1L inventor <br />the above mentioned facility were within the allowable ports for this variations <br />for <br />* quarter. (No in Column l3 of the Inventory Reconciliation Sheet) <br />❑ Inventory variations exceeded the aLlovable 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) releise. (Yes in Column 13 of the <br />Inventory Reconciliation Sheet) <br />List date, tank f, and amount for all variations that exceeded the <br />allowable licnits. <br />Date rank f Amount <br />2. <br />3. �. <br />y � <br />4. ....y <br />NVIR0NM' iALF-!EA Ted <br />Additional daces/amouots shall be continued on a separaLtRe�rIsheet[of J' � <br />Paper and attached. <br />If the source of the variation which.etceeded 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 aubmi <br />Quarter. tced withiISn days of the end of each <br />Quarter i - January --> March <br />Quarter 2 - April --> June <br />Quarter 3 - July --) September <br />Quarter 4 - October --> <br />December <br />Send to: SAN JOAQUIN LOCAL HEALTH DI:iTR IC -1- <br />160 1 E. Haze I i On . 1' . 0 . HOx 2OO') <br />40 10/86 Stockton, CA 95201 460-67b1 <br />