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1 <br />9 <br />Facility Name: <br />r tr <br />INVENTORY RLCONCILI1kTION <br />CT 0 3 i <br />QUARTERLY SUMMARY REPORT FORM`-'' 5{�! '+ ; {'J' r"!__ <br />-"E:!� Tank # Size Product <br />Facility Address: '�S U3 t_Ak+R;W aQ <br />Telephone: <br />Person Filing <br />Report: I F�fLND <br />F, I hereby certify under penalty of perjury that .all inventory variations <br />for the above mentioned facility were within the allowable limits for <br />this quarter. (No in Column 13 of the Inventory 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 varia- <br />tion tion was not due t0 unauthorized (.Leak) release. (Yes In Column 13 of <br />the Inventory Reconciliation Sheet). <br />List date, tank #, and amount for all variations that exceeded <br />the allowable limits. <br />Date Tank # Amount <br />2. <br />3. <br />4. <br />5. <br />Additional dates/amounts shall be continued on a separate sheet <br />paper and attached. <br />If the source of the variation which exceeded allowable limits was <br />due to a leak, the incident shall be reported to San Joaquin Local <br />Health District; Environmental Health Division,' within twenty-four <br />(24) hours and an unauthorized release report submitted. <br />The quarterly summary report shall be submitted within fifteen (15) days <br />of the end of each quarter. <br />Quarter 1 - January ---------- >March <br />Q rLer <br />2 - April ------------->June <br />ua <br />Qrto 3 - July ------------- >Septembe <br />Quarter 4 - October ---------->December <br />Send to: SAN JOAQUIN LOCAL HEALTH DISTRICT <br />1601 E. Hazelton, P.O. Box 2009 <br />Stockton, CA 45201 468-3420 <br />LI1 23 019 10/86 <br />