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INVENTORY RECONCILIATION <br /> .!A N 13 i�r <br /> QUARTERLY SUMMARY REPORT FORM EiVViRf.(4�G I <br /> � / PERMIT l�EI2V I�:ES <br /> Facility Name: /1l'�O7i0� /QjE C'f _ Tank # Size Product <br /> Facility Address: aE k. <br /> Telephone : Q -,23Y- 33 -&I - <br /> Person Filing <br /> Report P /+q U/0L'i0 <br /> E] 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. (Ho 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, task #, and amount for 211 variations that exceeded the <br /> allowable limits. <br /> Date 'Tank # Amount <br /> 2. <br /> 3. <br /> 4. <br /> 5. <br /> Additional dates/amounts shall be continued .ou a separate sheet of <br /> ,paper and attached. <br /> If the source of the variation which- exceeded al-lawable 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 1 - .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 ] Lol[ , P .O . Box 2009 <br /> Stockton , CA 95201 466-67851 <br /> UCT 40 10/ 86 <br />