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INVENTORY RECONCILIATION <br />QUARTERLY SUMMARY REPORT FORM ENV! RG1rc:: iAL HEALTH <br />, FERMIT/SERVICES <br />facility Name: <br />as <br />Faeilitr Address: iiiii am A te' <br />Telephone: 3L13 - <br />Person <br />L13_Person Filing <br />Report _ --RE-T7 y JAN,£ <br />Tank i Size i Product <br />10-4)0 <br />U . <br />° <br />7— <br />I <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. (No in Column 13 of the Inventory 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 />was not due to ao unauthorized (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 i Amount <br />2. <br />3. <br />4. <br />5. <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 15 days of the end of each <br />quartcr. <br />Quarter 1 - January --> Marc <br />Quarter - AV --> June <br />Quarter 3 - July --> sepcewher <br />Quarter 4 - October --> Qececuber <br />Send co: SAN JOAQUIN LOCAL HEAL1'li DISTKIC1' <br />1601 E. l' . 0 . Box M09 <br />SLockton, CA 95201 460-6781 <br />T 40 10/86 <br />