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A 7L <br /> �. k4NYENTORY RECONCILIATION <br /> ,..' �,�yJC�#UARTERLY SUMMARY REPORT FORM <br /> c Tank € size Product <br /> Fa c i 1 i t Name: �`, � � /(�/4 ^ <br /> F ( C0171�.EL� 7,CW �jaT 400 , 'E <br /> Facility Address: v�v�// '�?J/L"r7 A-J y 2- f 0 (f <br /> t)0 <br /> Telephone : <br /> Person Filing <br /> Report <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. (Ko 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 variation <br /> was not due to an unauthorized (leak) release. (Yes in Column 13 of the <br /> Inventory Reconciliation Sheet) <br /> List date, tank #, and amount for all variations that exceeded the <br /> allowable Limits. <br /> Date Tank t Amo/u/nt <br /> / <br /> z. / T �a7 41s <br /> 3. � f <br /> 4. r /U/`� /7U�-/ <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 health <br /> within 24 hours and an unauthorized release report submitted. <br /> 11;c quarterly summary report shall be submitted within 15 days of the end of each <br /> quarter_ <br /> Quarter I - January March - <br /> Quarter 2 - April -- --> June <br /> Quarter 3 - July --> September <br /> Quarter 4 - October -} December <br /> Send to: SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E . Haze 1 L rat? , P .0 _ liox 1009 <br /> SLoc€cton , CA 95201 466 -67bl <br /> UI.,T 40 10/ 86 <br />