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INVENTORY RECONCILIATION <br /> QUARTERLY SUMMARY REPORT FORM <br /> Facility Name: (� � f�p�p yQ k1T 'tank i <br /> Size Product <br /> Facility Address: p _�,��U}y �� 0 OcU I �Pzs7 <br /> L SSU E XL <br /> 95330 <br /> Telephone : -�709- a('5? �S/ <br /> Person Filing <br /> Report fj Z/ /�iL - 7L�fM1SP �@�"Ylc <br /> I hereby certify under penalty of perjury that all inventory _n... c,_r <br /> the above mentioned facility were within the allowable limits for- <br /> Chis <br /> quarter. (Ho in Column 13 of the Inventory Reconciliation Sheet) <br /> ElInventory 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 Column13 of the <br /> Inventory Reconciliation Sheet) <br /> List date, tank f, and amount for all variations that exceeded the_, <br /> allowable limits. <br /> / Date Tank f Amount <br /> J\ Z <br /> Y� rFiViRONMENTAL H'eALT'' <br /> 100 3. IERM!TISERVICF'` <br /> 4- <br /> 5. <br /> Ariditionai datesjamounts shall be continued on a separate sheet of <br /> paper and attached. <br /> If the source of the variation which. esceeded 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 DIS'T'RICT <br /> 1601 E. Hazelton , P .0 - Box 2009 <br /> Stockton , CA 95201 466-67b1 <br /> IGT 40 10/86 <br />