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1� <br /> INVENTORY RECONCILIATION AR I b <br /> QUARTERLY SUMMARY REPORT FORM <br /> ENVIROMEIVTAL HEALTH <br /> r l -/SERVICES <br /> Facility Name: ANALDW f•✓ou,e/ 6, f.A-0CRoe-. Tank # Size Product <br /> Facility Address: fid/ e. eA1AoGTeG 0 my un <br /> Telephone : SgG?. o-1 L,-r <br /> Person Filing <br /> Report jW pe," Y. c>7m*y/ <br /> ✓� I hereby certify under penalty of perjury that all inventory variations for <br /> the above mentioned facility were with» the allowable fnr rh:� <br /> quarter. (No in Column 13 of the Inventory Reconciliation Sheet) <br /> QInventory 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 #, and amount for all variations that exceeded the <br /> allowable limits. <br /> Date Tank it Amount <br /> 1. <br /> 2. <br /> 3. <br /> 4. <br /> S. <br /> Additional dates/amounts shall be continued on a separate sheet of <br /> Paper an,! att-nehe-1- <br /> .Z 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 submitted within 15 days of the end of each <br /> quarter- <br /> Quarter 1 — January --> March <br /> Quarter 2 — April --> June <br /> Quarter 3 — July --> September <br /> Quarter 4 — October --> December <br /> Send to: SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E . HazelLnn , P . O . Box 2009 <br /> Stockton , CA 95201 466-6781 <br /> UGT 40 10/86 <br />