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INVENTORY RECONCILIATION <br /> QUARTERLY SUMMARY REPORT FORM �Nfl Qu" <br /> Facility Name: ED -; .' ✓O ✓ + + r Tank i Stse^ Product <br /> Facility<Address: a 9' 3 41c .'4's Alz!: <br /> Telephone : <br /> Person Filings _ <br /> Report Si�;,� ;�D /GX <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. (No in Column 13 of the Inventory Reconciliation Sheet) <br /> E] 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) release. (Yes in Column 13 of the <br /> Inventory Reconciliation Sheet) <br /> List date, tank i, and amount for all variations that exceeded the <br /> allowable limits. <br /> Date Tank / Amount V <br /> 2. Ci? Iln <br /> 3. _ Asa? <br /> 4. ENVIROMENTAL HEALTH <br /> 5. PERMIT/SERVICES <br /> Additional dates/amounts shall be continued on a separate sheet of <br /> paper and attached. <br /> If the source of the variation whichexceeded allowable limits was due to <br /> a 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 1. - January --) March <br /> Quarter 2\% - April --> June <br /> er ] - July --) September <br /> Quarter 4 - October --) December <br /> Send to: SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 160L E . Haze1t (111 . P . O . M)x 2009 <br /> Stockton , CA 95201 466-67bL <br /> UGT 40 LO/ 86 <br />