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INVENTORY RECONCILIATION <br /> nn,(� <br /> QUARIERLY SUMMARY REPORT FORM <br /> Facility Name: w'(? 1�c' , CC\ \ p�J��� Tank i Size Product <br /> / I to, Go <br /> Facility Address: S2-0\k �k�k—o-q 2 b _ Lk% <br /> _yl1SLlvr ( Oo 4� <br /> Telephone : I A 3 - 20\\ <br /> Person Fili <br /> Report amt. IM\ \4t4PV N <br /> KI 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 13of the Inventory Reconciliation Sheet) <br /> ElInventory 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 1, and amount for all variations that exceeded the <br /> allowable limits. <br /> Date Tank 11 Amount <br /> 1. <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 /> a leak the incident shall be reported to S .J .L.H. D. Environmental lle.alth <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 /> Qua - r- 1 --> J <br /> Q��arter 3 - July --> September (�f <br /> Quarter 4 - October --> December <br /> Send to: SAN JOAQUIN LOCAL HEALTH 1)IS'1'l Iiur <br /> 1601 1" . Hazelton , P .O . Box 2009 <br /> Stockton , CA 95201 466-6781 <br /> UGT 40 10/86 <br />