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INVENTORY RECONCILIATION <br />QUARTERLY SUMMARY REPORT FORK <br />ratiliey Name: //a yh tMDMJ A lvoa . <br />facility Address: <br />Telepho <br />Person] ing <br />ReportY <br />Tank 01 Site Product <br />z o00 o ih•c <br />1 r <br />�!'1 <br />dL heccby certify under penalty of perjury that all inventory variations for <br />the above mentioned facility were within the allowable limits for this <br />4uaeeec. (No in Column l] of the Lnveacocy Reconciliation Sheet) <br />LaveaCocy variations exceeded the allowable limits for this Quarter_ I <br />hereby certify under penalty of perjury that the source for the variation <br />vas act due to as vaauthorized (leak) release. (Yes is Column I] of the <br />Laveatory Reconciliation Sheet) <br />List date. tank 1. aad amount for all variations Chat exceeded the <br />Allowable limits_ <br />Date Tank I kinount <br />1_ <br />Z_ <br />4- <br />5- <br />Additional <br />_S_ <br />Additional dates/a uocz shall be continued oa a separate sheet of <br />paper and attached - <br />Lf Che Source of the variation whichexceeded allowable limits was due Co <br />a leak the incident shall be reported to S.J.L.H.D. Eoviranmencal health <br />viChin 24 hours and an unaucharixed release report submitted. <br />TheQuarterly summary report shall be submitted within IS days of the end of each <br />Quarter_ <br />Quarter 1 January --J March <br />Qvac[cr 2 -April --> Jwu• <br />Quarter ) - CLIrcpcc t •r <br />Q�.artcr 4 - October --> Deccmbcr <br />Send co: SAN JOAQUIN LOCAL HEALTH DISTRICT <br />160L E. Hazeltine, I'.O. Hns 2009 <br />SLockcon• CA 95201 466-67bl <br />40 IQ/Hh <br />