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IIIIii l <br /> �'15VIT X410 <br /> INVENTORY RECONCILIATION 191989 QUARTERLY SUMMARY REPORT FORM <br /> E'NV1ROIJ <br /> Facility Name:Tfz/Arj KS 1916E 'r'I L�2 2 Tank # Si ERV1&8duct <br /> _ >0 <br /> Facility Address: t . 5 TF V� Li"' <br /> I AJTC=r <br /> Telephone: -°- ;1- <br /> Person tiling <br /> Report�l <br /> 0 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 Colum 13 of the Inventory Reconciliation Sheet) <br /> bInventory 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 /> T <br /> Inventory RACOnciliatioR sheet) <br /> List dates tank #v and amount for all variations that exceeded the <br /> allowable limits. <br /> Date Tank # Amount <br /> 2. <br /> 3. -� � `� C� � � Lo P-1) <br /> 4. <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 submitted within 15 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 /> Send to: SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. Hazelton, 11 .0 . Box 2009 <br /> Stockton , CA 95201 466-6781 <br /> UGT 40 10/86 <br /> dip <br /> • <br />