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INVENTORY RECONCILIATION <br />QUARTERLY SUMMARY REPORT FORM <br />Facility Nasse: &Q Imp M0a,4d A Notk <br />Facility Addre..: / so AN - <br />Telephone: X04 5/64Z -0/0F <br />Person Filing <br />Report 04Z�-o +.v/ we <br />Tank / Sice Product <br />]. p06 O INS <br />225 t <br />1 <br />Y hereby certify under penalty of perjury that all inventory variations for <br />the above mentioned facility were within the allowable limits for this <br />Qu4cCec. (go is Colum l3 of the Lnventory Reconciliation Sheet) <br />iaveaCory variations exceeded the allowable Limits for this Quarter. t <br />beceby certify under penalty of perjury that the source for the variation <br />was noC due to as uaauthorited (leak) release. (Yes is Column U of the <br />laventory Reconciliation Sheec) <br />List dates tank I. and Amount for ALL variations that exceeded the <br />allowable Limica. <br />Date <br />1_ <br />2. <br />4- <br />S. <br />Tank # Amount <br />AAdiCional dates/a uacs shall be continued on a separate shcec of <br />paper and at Cached_ <br />Lf the source of the variation whichexceeded allowable Limits was due Co <br />a leak the incident shall be reported to S.J.L.H.D. Environmental llcalch <br />within 24 hours and an unauthorized release report submicted- <br />The Quarterly summary report shall be submitted within 15 days of the end of each <br />Quarter. <br />Quay to 1 - Janu.ry --1 March <br />Q'IarCcr 2 - April --> J.".0 <br />Qwartcr 7 - July --) septcmher <br />q" Clcl 4 - octobcc --> ncccmbcr <br />Send to: SAN JOAQUIN LOCAL HEALTH DISTRICT <br />1601 E. Hazelt(ui, V.0. Nnr 2009 <br />Stockton, CA 95201 466-6781 <br />40 l0/N6 <br />