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Facility Name: <br />Facility Address:-� <br />Telephone: 2,— <br />Person filing <br />Report: jaw, <br />4-0 *0 <br />ENTORY RECONCILIATION <br />QUARTERLY SUMMARY REPORT FORM <br />L <br />W WIPILU <br />Tank # Size Product <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) r <br />the Inventory Reconciliation Sheet). ) el ease' (Yes �n Column 13 of <br />List date, tank #, and amount for all variations that exceeded <br />the allowable limits. <br />Tank # <br />Amount <br />�- tQ Getil <br />fi �,�1 Gol <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 />E -n V E <br />Qcarter2 � April ------------ >June <br />E� <br />Quarter 3 - July ------------- >September JUL 0 6 19,99 <br />Quarter 4 - October ---------- >December LNVIkONMENTAL HEAL I <br />PERM SE.RviCES <br />Send to: SAN JOAQUIN LOCAL HEALTH DISTRICT <br />1601 E. Hazelton, P.O. Box 2009 <br />Stockton, CA 95201 468-3420 <br />EH 23 019 10/86 <br />