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INVENTORY RECONCILIATION <br /> QUARTERLY SUMMARY REPORT FORM <br /> Facility Name:ri2ANIC< /DIVE y6r,,nJ-0.1� Tank I Size Product <br /> L14 tZ <br /> Facility Address: ���1 cj o 'E > ;r ,_ <br /> Telephone : 1ti)n i- n3 r- Of 7 5 <br /> Person Fi ing ,,�� rr <br /> Report ��L Y , ��� <br /> E= <br /> I hereby certify under penalty of perjury that all inventory variations for <br /> the above mentioned facility were within the allowablqMJi,mits for this <br /> quarter. (No in Column 13 of the Inventory Reconcilia�".- eet Y <br /> -- �, <br /> JAN 91r-C3 <br /> Inventory variations exceeded the allowable 'limits f ,�ylh�i1�16 <br /> ' <br /> hereby certify under penalty of perjury that the sou d� lie,.:var'wlon <br /> vas not due to an unauthorized (leak) release. (Yes in `13'of 66P <br /> Inventory Reconciliation Sheet) <br /> List date, tank 1, and amount for all variations that exceeded the <br /> allowable limits. <br /> C <br /> Date Tank * Amount <br /> s. /a-,2-pc <br /> 3. l? - 77l� �1 <br /> S.. I -Ah -89 Z) <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 <br /> Environmental Health <br /> p S .J .L.H.D. <br /> within 24 hours and an unauthorized release report submitted. <br /> The quarterly summary report shall be submitted within IS days of the end of each <br /> { quarter. <br /> Quarter 1 - January --> March <br /> Quarter 2 - April --> June <br /> Quarter 3 - July --> Scptemher <br /> Quarter 4 - October --> December <br /> Send to: SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E . Hazelton , P .O . Box 2009 <br /> Stockton , CA 95201. 466-6781 <br /> UGT 40 10/86 <br />