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du 7 ^V <br /> INVENTORY RECONCILIATION <br /> QUARTERLY SUMMARY REPORT FORM ETWIRONIF- TAl- 9EP,LTH <br /> _j VF-F, 1/SERVICES <br /> Facility Name: 4l�(7 Tank # Size Product <br /> Al 0 <br /> Facility Address: LLf <br /> IV, A/67,/ <br /> erir fer_ gj. ClOY& <br /> Telephone : X09'- S-Co ! ___-- <br /> Person Filing <br /> Report :TJO 10t4 u� . WO IRA I <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 Coiumn 13 of the inventory Reconciliation Sheet) <br /> QInventory 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 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 # Amount <br /> 2. <br /> 3. <br /> 4. <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 al-lowable 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 lune <br /> Quarter 3 - .July --> September <br /> Quarter 4 - October --> December <br /> Send to: SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E . HazelL011 , P .Q . Box 20019 <br /> Stockton , CA 95201 466-6781 <br /> UGT 40 10/ 86 <br />