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.00 6 <br /> s <br /> INVENTORY RECONCILIATION <br /> QUARTERLY SUMMARY REPORT FORM <br /> Facility Name: Za �pTank I Size Product <br /> �f � mG e U 'I <br /> Facility Address: WJ . <br /> a,4t&Ca CA rtS�3G <br /> Telephone : <br /> Verson Filing _ <br /> Report TPl4�y .� , Gln Mo slei' <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. (No in Column 13 of the Inventory Reconciliation Sheet) <br /> DInventory 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 Sheep) ' <br /> List date, tank #, and amount for all variations that exceeded the <br /> allowable limits. <br /> Date Tank # Amount ` <br /> 1. , <br /> 2. d I <br /> 3. L!"'Vffx `r:, ENTAL HEALTH <br /> 4. FERMIT/SERVICES <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 ?larch <br /> Qvaarter 2 - April --7 ,dune <br /> Quarter 3 - 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 466-6751 <br /> UCT 40 10/ 86 <br />