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u <br /> INVENTORY RECONCILIATION SAN j3 'i983 <br /> QUARTERLY SUMMARY REPORT FORM <br /> C�SLTH <br /> Facility Name:`iZA ti KS pNF (4D? (b (i}a12T Tank # Size Product <br /> Facility Address: C E. 'ly r 000 L 6 <br /> MAhI`TCC ('.A 5330 O C �LMge <br /> Telephone : '�<�q- X5`7.5 <br /> Person Filing <br /> Report <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 Colum 13 of the Inventory Reconciliation Sheet) <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 /> 2. <br /> 3. <br /> 4. /0 -88 <br /> 5.. l l I <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 Uealth <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 --> 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 /> J <br />