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INVENTORY RECONCILIATION <br /> QUARTERLY SUMMARY REPORT FORM <br /> TOT O11ql Tank t Size Product <br /> Facility Name: 1 ID O re WIck,r <br /> Facility Address: —n L- Ca -oU<- a 1 a LA h 2 ' <br /> 1- '0, O 01'1 uw . <br /> Telephone : �C�- 333 - r17�7 <br /> Person Filing <br /> Report �An\� Iv�hctm� <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. (Ho in Column 13 of the inventory Reconciliation Sheet) <br /> ElInventory variations exceeded the allowable limits for this quarter. I <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 f Amount <br /> 1. <br /> 2. <br /> 3. <br /> 4. <br /> 5. <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 al-lovable limits was due to <br /> a leak the incident shall he reported to S .J .L.H. D. Environmental dealth <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 <br /> Quarter 2 - April --) June <br /> Quarter 3 - July September <br /> Quarter 4 - October December <br /> Send to: SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E . Hazelton , P .O . Box 2009 <br /> Stockton , CA 951201 466-6781 <br /> UGT 40 10/86 <br />