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INVENTORY RECONCILIATION 00T -1 <br /> QUARTERLY SUMMARY REPORT FORM <br /> E-1P tRONMENTAI.HEAL',!. <br /> ! <br /> ��}} h tT <br /> Facility Name: +/p7 Q Tank # Size oduct <br /> Facility Address: �� / N. Aq7/.*� <br /> r SG <br /> Telephone ; .?09 0?1 9�- Ys-b / <br /> Person Filin / <br /> Report �'l�J'�/-- - y�, WD Iwo S41 + <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. (No in Column 13of the inventory Reconciliation Sheet) <br /> �nventory variations exceeded the allowable limits for this quarter. I <br /> hereby certify under penalty of perjury that the source for the variation <br /> vas not due to an unauthorized (leak) release. (Yes in Column13 of the <br /> Inventory Reconciliation Sheet) <br /> List date, tank #, and amount for all variations that exceeded the <br /> allowable limits. <br /> Date Tank # Amount <br /> 2. <br /> 3. <br /> 4. <br /> S. <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 /> The 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 <br /> Quarter 4 OctStft — ccmbey-, ', <br /> Send to: SAN JOA i]IN L0CAL� -HEALTH DISTRICT <br /> 1601 E . Haze] L cin , P .O . Box 2009 <br /> Stockton , CA 95201 466-6781 <br /> UGT 40 10/86 <br />