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INVENTORY RECONCILIATION <br /> QUARTERLY SUMMARY REPORT FORM <br /> Facility Names Lll1 (� \f1 d�I Tank I Sue Product <br /> Facility Addreset -- L <br /> Telephone : _ <br /> Person Fi11n / <br /> Report � s4 <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 Colum 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 varistioa <br /> was not due to an unauthorized (leak) releiae. (Yes in Colum 13 of the <br /> Iaveotory Reconciliation Sheet) I <br /> List date. Cask /, sad amount for all variations that exceeded the <br /> allowable linin. <br /> Date Tank I Amouat P05ex, 1 �g9� <br /> 1. <br /> 2. APR i 1st.' <br /> 3. ENVIROMEvTAL HEALTH <br /> 4. FERMIT/SERVICES <br /> S. <br /> Additional daces/amount. .hall be contioucd oo ■ separate sheet of <br /> paper and aCtached. <br /> if Che Bootee of Cho variation vh,ch exceeded allow btc limits as due to <br /> a leak the incident shall be rcportr_d to S . J I, . H D . Environmental licalth <br /> within 24 hogs and an ,nao0,or , crd release report submiCCed. <br /> ITe Q..arterly Bu.m r-y report shall br Bobmi (Ced vl(htn IT days of the end of each <br /> �oartcr <br /> Quarter I - January --> H.I' Cli <br /> �VAACCCC 2 - AprLl J.nr <br /> Quarter ) - July __) Septcmhrr <br /> Q"Arter 6 - October --> D.�crmher <br /> Send to: SAN JOAQUIN LOCAI. HEALTH DISIHICT <br /> 1601 !i . Hazt• II ,In . 1' .0 Ros /0W) <br /> Stockton . (.A 95201 466 - 61bl <br /> U(;1' 40 10/86 <br />