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INVENTORY RECONCILIATION <br /> QUARTERLY SUMMARY REPORT FORM <br /> Facility Name: _kiirl �DtJ.t�f�o�:e <br /> i l�ariG/2cc_ Tank #J. <br /> Size Product <br /> Facility Address: j /1r'��' e. <br /> �vi E c�i9eTE� <br /> Telephone : (2c, -76 S <br /> Person Filing' <br /> Report �'Ctiu/JUITYinati� <br /> QI hereby certify under penalty of perjury that all inventory variations for <br /> '6e above mentioned facility were within the allowable limits for this <br /> quarter. (No in Column 13 of the loventory 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 Column 13 of the <br /> Inventory Reconciliation Sheet) <br /> List date, tank f, and amount for all variations that exceeded the <br /> allowable lis,its. <br /> Date Tank E 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 /> Lf <br /> i <br /> the source of the variation which exceeded allowable limits was due to <br /> a leak the incident shall be repor ccd to S .J . L. N . D . <br /> within 24 hours and an unauthorized release report submtitcedo Environmental Health <br /> The quarterly summary report shall be Fubmicced within 15 days of the end of each <br /> quarter. <br /> Quarter I - January <br /> Qlarter 2 - April --> Julie <br /> arcer 3 - July --) JcpCcmh��r <br /> Quarter 4 - October --) (k cembcr <br /> Send to: SAN JOAQUIN 1.0CA1. HEALTH UISTHICI' <br /> 1601 l: . H.Ize 1 t cin . p . U . lic>x ZUU') <br /> 140 10/ 86 Stockton , CA 95201 460 - 67b1 <br />