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INVENTORY RECONCILIATION <br /> QUARTERLY SUMMARY REPORT FORM <br /> Facility Name: s-4('roc 'tank Size. Product <br /> vz-rJ <br /> Facility Address: 7v/ L cHR!P-r,_W W47 <br /> L`z c,' 9.S'2o,(v . <br /> Telephone : <br /> Person Filing <br /> Report _ AW191_D0©.v Y_ e2irhe0,? 1 <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 Column 13of the Inventory Reconciliation Sheet) <br /> -aventory 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) releise. (Yes in Column 13 of the <br /> Inventory Reconciliation Sheet) <br /> List date, tank I, and amount for all variations that exceeded the <br /> allowable limits. <br /> Date Tank f Amount <br /> 1. � 11►`l.1 ��. <br /> 2. <br /> 3. OCT 1 i ? <br /> 4. <br /> S. EN HEALTH <br /> FERMIT/SERVICES <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 . Environmental Health <br /> within 24 hours and an unauthorized release report submitted. <br /> The quarterly summary report shall be Fubmitted within 15 days of the end of each <br /> quarter. <br /> Quarter I - January --> March <br /> Quarter 2 - April --> June <br /> Quarter ) July --> Septemhi•r <br /> Quarter 4 - October --> December <br /> Send to: SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 160L E. Haze 1 L on , P . O . liox 2009 <br /> Stockton , CA 95201 466-67b1 <br /> W;T 40 10/86 <br />