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INVENTORY RECONCILIATION <br /> JAN <br /> QUARTERLY SUMMARY REPORT FORM ENFIERtMEINITERV CESAL LTH, <br /> taciLity Namet E0 �oc/i� 'fi b/ Tank size"z* <br /> 10 ,b, . - <br /> raeilttr Address: y79>3 Ltxv:�,s /}. <br /> S�< <br /> Telephone1 - oo � <br /> Person Filing <br /> Report i <br /> 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. (No in Column I3 of the Loventocy Reconciliation Sheet) <br /> Inventory 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) releise. (Yes in Column 17 of the <br /> Inventory Reconciliation Sheet) <br /> List date, tank f, and amount for all variations that exceeded the <br /> allowable limits. <br /> Date Tank ! Amount <br /> I. <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 allowable limits was due to <br /> ■ leak the incident shall be reported to S .J .L.H . D . Environmental health <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 --) March <br /> Qjarter 2 - April --> June <br /> Quarter J - July --) Septemher <br /> Quarter 4 - October --) lkeember <br /> Send to: SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E . Ilazcll(ai , P .O . Box 1009 <br /> Stockton , CA 95201 466-67b1 <br /> CT 40 10/ 86 <br />