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W y v <br /> INVENTORY RECO <br /> N14$6TI01�`��0" �Sa <br /> QUARTERLY SUMMARY REPORTIO�R�M�P�� S <br /> 5� <br /> Facility Name: Tail i Size. Product <br /> 6'" <br /> Facility Address: _/OY� 5 CFFFPi�iIEF � r u/PsrF arc <br /> Telephone : 33y < -o n <br /> Person Filing <br /> Report <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 /> van not due to an unauthorized (leak) rel"ce. (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 Sank E Amount <br /> 1 . <br /> 2. <br /> 3- <br /> 4. <br /> S. <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 --> Scptcmhcr <br /> Quarter 4 - October --) December <br /> Send co: SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 160L E . HaZeILnn , P .O . ROX 2009 <br /> Stockton , CA 95201 466 -6781 <br /> L1CT 40 10/86 <br />