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�W 0 <br />INVENTORY RECONCILIATION <br />QUARTERLY SUMMARY REPORT FORM <br />Facility Name; rna,�> s <br />Facility Address: 2 3q <br />\i1n. PA :'S 3lh <br />Telephone: _ae9 599- �eII1S <br />Person Filing <br />Report ` T Y`(1�\' -%e,Y,, <br />46 <br />RECEIVED <br />APR 259^"0 <br />ENVIRONMENTAL HEALTH <br />PERMf1T/:,E4'VICE"S <br />Tank t Size Product <br />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 />E] 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) 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 f 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 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 />quarter. <br />Quarter I - January --) March <br />Quarter 2 - April --> June <br />Quarter 3 - July --) September <br />Quarter 4 - October --) December <br />Send to: SAN JOAQUIN LOCAL HEALTH DISTRICT <br />1601 E. Ilazelcim, P.O. Box 2009 <br />Stockton, CA 95201 466-6781 <br />U(;T 40 10/86 <br />