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INVENTORY RECONCILIATION <br /> QUARTERLY SUMMARY REPORT FORM <br /> Facility Name: /!d a�C T nk # Size Product <br /> ,,��jj�� A v o w W1as t ©, <br /> Facility Address: ,j� Al. /�ldt►? �jf`. <br /> — a <br /> Telephone : CP(}91 - 0229- 30401 <br /> Person Filin <br /> Report C/'/` J, U)014cski <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 /> 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, tank #, and amount for all variations that exceeded the <br /> allowable limits. <br /> Date Yank # Amount <br /> 1. l'/Cas 0. See G'o fes M ri/e <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 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 --> .lune <br /> Quarter 3 - July --> September <br /> Quarter 4 - October --) December <br /> Send to: SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E . daze 1 t oll , P .O . flax 2009 <br /> SLockton , CA 95201 466-6781 <br /> UGT 40 10/ 86 <br />