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. 11 <br />INVENTORY RECONCILIATION <br />QUARTERLY SUMMARY REPORT FORM <br />FERMIT/SERVICES <br />FacL1Lty Name: i m 1 z� --1— <br />Facility Address: 1+2 t i,, a <br />Telephone: <br />Person Filing <br />Report L�-t-y Jill Ls <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 an unauthorized (leak) releise. (Yes in Column 13 of the <br />Inventory Reconciliation Sheet) <br />List date, tank #, and amount for all variations that exceeded the <br />allowable limits. <br />Date Tank Amount <br />1. <br />2. <br />3. <br />4. <br />5. <br />Additional dates/amounts shall be continued on a separate sheet of <br />paper 2nd 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 suaxaary report shall be submitted within 15 days of the end of each <br />quarter. <br />Quarter 1 - January --> March <br />Quarter 2 - April --> June <br />Quarter Z - July --> Septemb(:r <br />Quarter 4 - October --> December <br />Send to: SAN JOAQUIN LOCAL HEALTH DISTRICT <br />160L 1:. Hazv 11 ()n , P .0 . 1iox ZO09 <br />Stockton, CA 95201 400-6781 <br />T 40 l0/H6 <br />N 1111111 1�h� <br />IN> t;�'tll lil"■r: <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 an unauthorized (leak) releise. (Yes in Column 13 of the <br />Inventory Reconciliation Sheet) <br />List date, tank #, and amount for all variations that exceeded the <br />allowable limits. <br />Date Tank Amount <br />1. <br />2. <br />3. <br />4. <br />5. <br />Additional dates/amounts shall be continued on a separate sheet of <br />paper 2nd 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 suaxaary report shall be submitted within 15 days of the end of each <br />quarter. <br />Quarter 1 - January --> March <br />Quarter 2 - April --> June <br />Quarter Z - July --> Septemb(:r <br />Quarter 4 - October --> December <br />Send to: SAN JOAQUIN LOCAL HEALTH DISTRICT <br />160L 1:. Hazv 11 ()n , P .0 . 1iox ZO09 <br />Stockton, CA 95201 400-6781 <br />T 40 l0/H6 <br />