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INVENTORY RECONCILIATION <br /> QUARTERLY SUMMARY REPORT FORM <br /> Facility Name: � .ob.'4[ &los�r Tank i Size Product <br /> -:26xv 4v. ✓l1aUc71 /Lo/td e— d�w<-L w , <br /> Facility Address: .6_,ddK G aW L <br /> 4 0 [h 9fa S�/-f9c� 3 vvo At 4 <br /> Telephone : C229 f y- 7aZ� 0000 p_ <br /> Person FilingGar a.T.-. - <br /> Report i /�//76Z7Z, / 14*A,7– &;K C' . or 0C �z7IS� <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 1, and amount for all variations that exceeded the <br /> allowable limits. <br /> Date Tank R Amount <br /> 2. <br /> 3. HEALTH <br /> 4. EHRomt FERIA Y�SERVICES <br /> S. <br /> Additional dates/amounts shall be continued on a separate sheet of <br /> p+per 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 IS days of the end of each <br /> quarter_ <br /> Quarter I - January --) March <br /> Quarter 2 - April --> June <br /> Quarter 3 - July --) Septcmhcr <br /> Quarter 4 - October --> Occrmber <br /> Send to: SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 160L E . Ilazeltun , P .O . Rox 2009 <br /> Stockton , CA 95201 466-67bl <br /> lIC1' 40 l0/ K6 <br />