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r <br /> � y 1 <br /> INVENTORY RECONCILIATION <br /> QUARTERLY SUMMARY REPORT FORM <br /> ' CNFIE�MIT/�ERVIC SHEALTH <br /> Facility Name: �;yA �,i/ ,� G <br /> Tank I Size Product <br /> Facility,Address: � <br /> �lt1ZT .e cu.4 e 4,�•. <br /> C474) 6r', pq <br /> TnCi-rn.r1 �•4 �jiSZ_)�, <br /> Telephone : l <br /> / LOW 0 3c-5 <br /> Person Filing <br /> Reportl'!:E,c/ <br /> I hereby certify under penalty of perjury that all inventory variations for <br /> -he above mentioned facility were within the allowable limits for this <br /> Quarter. (No is 'lolu 13 of the Inventory 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 /> vas 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 limits. <br /> Date Tank f Amount <br /> I. <br /> 2. <br /> 3. <br /> 4. <br /> S. <br /> Additional dates/amounts shall be continued on a separate sheet of <br /> paper and attached. <br /> i <br /> If the source of the variation whichexceeded allowable limits was due to <br /> a leak the incident sha1.1 be reported to S J . L. N . D . Environmental lieaIth <br /> within 24 hours and an unauthorized release report submitted. <br /> The Quarterly summary report shall be aubmitced within 15 days of the end of each <br /> quarter. <br /> Quarter I - January --) Marcli <br /> `1arter 2 - April -->_June�J'�--- <br /> Quartcr ] July--__) jcptcmher <br /> Quarter 4 - October --) Dkocvmber <br /> Send co: SAN JOAQU tN LOCAL HEALTH DISTRICT <br /> 1601 1: . 1'.aze 1 ( t)n , p . 0 . lit)x 20(1'J <br /> 40 l0/ 1i6 Stockton , CA 95'201 466 -67b1 <br /> c.1' <br />