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a ,-- <br /> Ii w• <br /> INVENTORY RECONCILIATION <br /> QUARTERLY SUMMARY REPORT FORM ENVIROIME-NTAL HEALTH <br /> FERMIT/SERVICES <br /> Facility Name: MIGRA Tank # Size Product <br /> Facility Address: /V. i've;' St: <br /> Iffa,f Ca. 3G <br /> Telephone : 090cl -.239- <br /> Person Filing <br /> Report JPr_T c1 . JA)014o s 1K,' - <br /> 0 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 /> E] 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 Tank # Amount <br /> 1. <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 --) lurch <br /> Qaarter 2 - April --> June <br /> Quarter 7 - July --> September <br /> Quarter 4 - October --> December <br /> Send to: SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E . Hazelton , P .O . Box 2009 <br /> Stockton , CA 95201 466-6781 <br /> UGT 40 10186 <br />