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INVENTORY RECONCILIATION <br /> QUARTERLY SUMMARY REPORT FORM FE�g01gF^ <br /> Facility Name: p� � ' {n�/ �1j��( Tank # Size Pfo p; <br /> QOcS <br /> Facility Address: ,07/ Al- #nfifJ UpU <br /> iin,*A rtz.4- "4- UUPJ <br /> Telephone : Opt a39 - 7q"l <br /> Person Fil{{ng <br /> Report / 0LgAZw <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 /> 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 /> L- _ 0-3/ 3 4113 <br /> 2. /901 l f SFS <br /> 3. la-/D <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 --> June <br /> Quarter 3 - July --> September <br /> Quarter 4 - October --> December <br /> Send to: SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E . 1lazelton , P .O . Box 2009 <br /> Stockton , CA 95201 466-67b1 <br /> LJ(;T 40 10/ 86 <br />