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INVENTORY RECONCILIATION <br /> QUARTERLY SUMMARY REPORT FORM <br /> Facility Name: _C�A,,ZL FI17T Tank i size Product <br /> / D z <br /> Facility Address: �00 �6LI o�c/ /,�dG 0SO - - <br /> n���✓Ti <br /> Telephone : X09 -,tfz3— q2 -6 <br /> Person Filing_ <br /> Report IERR / LA.i/GST9F` <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 i1 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 IJ of the <br /> Inventory Reconciliation Sheet) <br /> List date, tank /, and amount for all variations that exceeded the <br /> allowable limits. FgEalyzg <br /> Date Tank / Amount <br /> 2. AUG 1 5 W8 <br /> J. EWROMENTAL HEALTH <br /> 4. FERMIT/SERVICES <br /> 5. <br /> Additional dates/amouuts 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 .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 /> garter 2 - April --) June <br /> atter J - July --) Septcmbe �y:g� <br /> Quarter 4 - October - Y-Dcccmber <br /> Send toe SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. liazelton , P .O . [lox 2009 <br /> Stockton , CA 95201 466-67bL <br /> UCT 40 10/86 <br />