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INVENTORY RECONCILIATION <br /> QUARTERLY SUMMARY REPORT FORM �F•N ZN <br /> Q RpMEN�DKV\CES <br /> Facility Name: C,,gOL /C ,IcH`2 fN% Tank I tProduct <br /> FacilitAddress: o v o <br /> yi 2 <br /> t7-17Te614 T/I 9533 <br /> Telephone : Z a Y2 <br /> Person Filing <br /> Report TRe 19A/G5TAr%' <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 /> 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 i, and amount for all variations that exceeded the <br /> allowable limits. <br /> Date Tank f 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 --) March . <br /> Quarter 2 - April --> June <br /> Quarter 7 - July --) September <br /> Quarter 4 - October --) December <br /> Send to: SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E . HazelLnn , P .O . Rox 2009 <br /> Stockton , CA 95201 466-67b1 <br /> UGT 40 10/86 <br />