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INVENTORY RECONCILIATION <br /> QUARTERLY SUMMARY REPORT FORM <br /> Facility Name:hZAQKSAIr STnaYi�D/r)A�.T '3. Tank # Size Product <br /> Facility Address: O j r 7 i E / V17 <br /> A I 0_ 5.3 3 �_ <br /> Telephone : � - X301-r 75. E14 '_ <br /> Person F in <br /> Report 6 <br /> I hereby certify under penalty of perjury that all inventory variatiocs for <br /> the above mentioned facility were within the allowable A4,4its96rr� this <br /> quarter. (No in Column 13 of the Inventory HEALTH <br /> F"ER 1"1T/: L RVI CES <br /> Inventory 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 # Amount <br /> � 1 /0- y—Sy / <br /> s. <br /> 3. <br /> I 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 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 IS days of the end of each <br /> - quarter. <br /> Quarter I - January March <br /> Quarter 2 - April --> June <br /> Quarter 3 - July --> September <br /> Quarter 4 - October --> December <br /> i <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 /> r <br /> J <br /> s <br />