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INVENTORY RECONCILIATION AH qz-7 <br /> QUARTERLY SUMMARY REPORT FORM ENVIROMENTAL HEALTH <br /> ' `,',AIT/SERVICES <br /> Facility Name: Lid a�u �t,:�f ��y� Tank i Si=e Product <br /> az <br /> Fscility 'Address: _1Q p, k ox .3Gr�y crxGn� s ktpi �� <br /> Telephone : t')�°l/ 3,3Y- 7c":2`J ° CWoC-4r- <br /> - <br /> Person Filingn aL i zro- <br /> Report 7, I�i?.�/LTI� i� MGk. '`2 old%-z <br /> 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 13of the Inventory Reconciliation Sheet) <br /> Inventory variations exceeded the allowable limits for thin quarter. I <br /> hereby certify under penalty of perjury that the source for the variation <br /> was not due to an unauthorized (leak) releaae. (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 / Amount <br /> I. <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 . Env ironmentaL 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 co_ SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E . Ha•r.ellon , P .O . Box 2009 <br /> SLockcon , CA 95201 666 -678L <br /> ur,T 60 lnis6 <br />