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INVENTORY RECONCILIATION <br /> QUARTERLY SUMMARY REPORT FORM <br /> Facility. Name: �j/ � N/ ��� � Tank / Size_I^pcd�ct <br /> C) 0 (. Afl_eAr)c'D . <br /> FacilityWdress: 17. 6 IV, W, 4S©E)N AIA V 0 Q 0 5'u EER uNLFADF <br /> ' T0Cbc7bN C A • 14r 01-s— <br /> Telephone : 909 64( <br /> Person Filing r <br /> Report Cg/y 4 /l/ PII LC A �- <br /> [a/, 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 toventory 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 so unauthorized (leak) releiae. (Yes in Column 13 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 / Amount <br /> 3. <br /> N <br /> ` JAN 0 2 1991 <br /> ;VIRONMENTAL HEAf H <br /> 1)01!Tl'3ERVICES <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 at-lovable limits was dun: 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 /> ire Quarterly summary report shall be submitted vithin 15 days of the end of each <br /> Quarter. <br /> Quarter 1 - January --) March `. <br /> Quarter 2 - April --5 June <br /> Quarter 3 - July --> September <br /> Quarte r(� - October --> December <br /> Send to: SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. Hazeltoll . P .O . ISOx 2009 <br /> Stockton , CA 95201 466-67bl <br /> EH 23 019 10/86 <br />