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INVENTORY RECONCILIATION <br /> QUARTERLY SUMMARY REPORT 'FORM <br /> Facility Name: kx a 0 Q a rae d 'Tank i Size Product <br /> �� ,,,,��,,rr Q S d <br /> Facility Address: ,Ss /Y. Mei/ V. <br /> hrad-teca CQ. 9s`33G <br /> Telephone : 0170q .234. 35101 <br /> Person Filing <br /> Report �.AJ. 41.10 <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, 13 of the Inventory Reconciliation Sheet) <br /> Inventory variations exceeded the allowable limits for this quarter. I <br /> h4reby 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 /> re Tank I Amount <br /> 2. <br /> 3. <br /> 4. 4 �CHL�1 S <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 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 /> qiarter 2 - April June <br /> Quarter 3 - July --? September <br /> Quarter 4 - October --) December <br /> Send to: SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 H . fazeILon , P .O . Box 2009 <br /> Stockton , CA 95201 466-6781 <br /> UGT 40 10186 <br />