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INVENTORY RECONCILIATION <br /> QUARTERLY <br /> SUMMARY REPORT FORM <br /> racLUty_ Manes OIL- // ( /// Tank I Size Product <br /> raeilitp-'Address: �5 9 / <br /> 5a <br /> Telephone: (2/.-V g33 936 c/ya <br /> Person Filing <br /> Report <br /> C] I hereby certify under penalty of perjury that all inventory variations <br /> the above nencioeed facility were within the allowable limits for this €•, a <br /> Quarter. (No in Colum 13of the Inventory Reconciliation Sheet) S' 1 <br /> N <br /> Inventory variatibes exceeded the allowable limits for this Quarter. ' i tiNVFERM SSERV C STH <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 /, and amount for all variations that exceeded the <br /> allowable Limits. <br /> Date Tank ! Amount <br /> 1. ��. 3o7-a • ��- tom- <br /> 2. y- 7 307— /-- <br /> 3. <br /> 07— /3. -51�(o- // 307-a • ///- �h w 3f <br /> 4. s/3- S 307- <br /> 5. /-3 307-a • 5dSF— 4A--t <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 Wealth <br /> Within 24 hours and an unauthorized release report submitted. <br /> Quarterly summary report shall be submitted within 15 days of the end of each <br /> srter. <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 DIS'l•KICT <br /> 1601 E. HazelLoll . P .O . Rox 2009 <br /> Stockton . CA 95201 466-6161 <br /> ;T 40 10/8 / ppTE I prwlC lk 0��1 <br /> )-7 <br /> 9 /-3 7 30�^ 99 t � S-7 <br /> 97- <br /> /07 <br /> 7/07 9/O� <br />