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INVENTORY RECONCILIATION <br /> QUARTERLY SUMMARY REPORT FORM <br /> Facility Name: eAe'4 ANT. mm <br /> 1 <br /> Facility Address: Jbo-�tyFttpQ R� <br /> Telephone : gs3- 9�S/ <br /> Person Filing <br /> Report ,8��//V�iLo7�q <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 /> Date Tank E Amount <br /> 1. <br /> �2. <br /> 3. <br /> 4. <br /> 5. <br /> Additional dateslsr .n., Ci"11 ±,m _•,;.xtic'. _.._ - ..,,,i ' <br /> paper and attached. <br /> If the source of the variation which. exceeded allowable limits was <br /> 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 /> Qjarter 2 - April --> June <br /> Quarter 1 - July September <br /> atter 4 - ctobcr -- ccm e <br /> Send to: SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. llazc ] Lon P .O. Box 2()09 <br /> 40 lO/86 Stockton . CA 95201 466-6761 <br /> " <br />