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01 <br />INVENTORY RECONCILIATIOR <br />QUARTERLY SUMMARY REPORT FORM <br />Facility Nave: w'.. or/o/ 4No, &/F'0' <br />Facility Address: �/ p ehla r-oe A <br />C& <br />Telephone: gofj y> zs2� <br />Person Filing <br />Report <br />Tank / Site Product <br />�a 000 O Ire <br />7 <br />L heccby certify under penalty of perjury that all inventory variations for <br />the above a.eationed facility vete within the allowable limits for this <br />quartet. (No in CoLuma 13 of the Inventory Reconciliation Sheet) <br />C] Iaveatocy variations exceeded the allowable Limit for this Quarter. I <br />beceby certify under penalty of perjury that the source for the variation <br />was not due to an unauthorized (leak) eelease. (Yec in Column 13 of the <br />Inventory Reconciliation Sheet) <br />I <br />List date. tack /. and amount for all variations that exceeded the <br />Allowable limits_ <br />Date Tank / Amouot <br />L <br />Additional dates/aaouots shall be conciaued oo a separate sheet of <br />PAPec and attached. <br />If the source of the variation whichexceeded allowable Limits was due to <br />A leak the incident ■hall be reported to S.J.L.H.O. Environmcntat llcalth n <br />within 24 hours and an unauthorized release report submitted. U <br />The quarterly summary report shall be submitted within 15 days of the end of tact, <br />quartcc- <br />Quarter i Janu.cy --) March <br />QQ•artcr 2 - April --) Junc <br />a rtcr I - July --> Scptc mbcr <br />Q`•+rter - October --> Occember <br />Send to: SAN JOAQUIN LOCAL HEALTH DISTRICT <br />1601 E. Hazclt.ln, P.O. ells 20009 <br />Slockton. CA 95201 466-67bl <br />40 10/86 <br />