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z <br /> INVENTORY RECONCILIATION <br /> QUARTERLY SUMMARY REPORT FORM <br /> Facility Name: /J <br /> ' Tank # Size Product <br /> Facility Address: S 1V. a uAS�Q 4 <br /> ,. <br /> Telephone : av?- o73?- s-- ?- <br /> Person Fi1Ing <br /> ReportMr .TPni+� G{Jd,f/las <br /> I hereby certify under peoalt f <br /> the above y operjury that all inventory variations for <br /> mentioned facility were within the allowablelimits for this <br /> quarter. <br /> (Ho in Column 13 of the Inventory Reconciliation Sheet) <br /> Inventory variations exceeded the allowable limits <br /> hereby certify under penalty of er'ur t for this quarter. I <br /> t+aa not due to an unauthorized (leak) releaseh(yes uineColumr� l3 offor thertheion <br /> Inventory Reconciliation Sheet) <br /> List date, tank #, and amount for 211 variations that exceeded the <br /> allowable limits. <br /> Date Zank # Amount / bew? Go4u,osRl 79-, <br /> 2.1. Now Iia (9'aP/+s f pr? <br /> 3. <br /> 4_ <br /> 5. <br /> Additional dates/amounts shall be continued ,on a separate sheet of <br /> Paper and attached_ <br /> IE the source of the variation which. exceeded al-lowable limits was due to <br /> it 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 /> The quarterly summary report <br /> quarter- shall be submitted within 15 days of the end of each <br /> qua <br /> Quarter I - January March <br /> Q71arter 2 - April --> June <br /> Quarter 3 -- July --) September <br /> Quarter 4 - October --? December <br /> Send to: SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E . Haze1uon , P .O . Dox 2{ 09 <br /> UGT 40 10/ 86 Stockton , CA 95201 466- 6751 <br />