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Facility Name:t <br />Facility Address: <br />Telephone: 'z <br />Person Filing <br />Report: <br />U �40 0 <br />INVENTORY RECONCILIATION <br />QUARTERLY SUMMARY RE=PORT FORM <br />Tank # <br />I I N.-A,L-A-: CD <br />JUL 0 9 1992 <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 was not due to 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 <br />1. <br />2 <br />3. <br />4. <br />5. <br />Tank # <br />4 <br />t <br />Amount <br />I M ��]l kc�flS <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 />clue 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 />Quarter 2 - April------------ >June <br />Quarter 3 - July ------------- >September <br />Quarter 4 -- October ---------- >December <br />Scnd to: SAN JOAQUIN LOCAL HEALTH DISTRICT <br />1601 E. Hazelton, P.O. Box 2009 <br />Stockton, CA 95201 468--3420 <br />Ell 23 019 10/86 <br />