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INVENTORY RECONCILIATION <br /> QUARTERLY SUMMARY REPORT FORM <br /> Facility Name: rol-lc' Tank # Size Product. <br /> ,^, // y� /d a dso Z o <br /> Facility Address: u�� /�. A167i? 7•` <br /> Telephone : 0709- ;?34-3 SG <br /> Person Filing <br /> ReporC TeP11y J . pl�ilos+�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 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 /> We Tank # Amount <br /> 2. <br /> on <br /> 3. ��fi'6ti,�.�� <br /> 11FAk Thi <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 --> Harch <br /> Quarter 2 - April <br /> Quarter 3 - July --> September <br /> Quarter 4 - October --> December <br /> Send to: SAN .JOAQUIN LOCAL HEALTH U15TRICT <br /> 1601 E . Haze 1 t nn , P . 0 . 1i0X <br /> Stockton , CA 95201 466-6751 <br /> LILT 40 LO/ 86 <br />