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a <br /> INVENTORY RECONCILIATION GOT 17 W' <br /> QUARTERLY SUMMARY REPORT FORM <br /> 'IVViR. Ni iC:IV lfi ii_h 1 <br /> PERMIT/SERVICES <br /> Facility Name: x )(n&t Tank # Size Product <br /> Facility Address: 1 3qq E. \�OSE�n rE Ay r ' <br /> I,4A1-re Lra <br /> Telephone : 331.3 <br /> Person Filing <br /> Report vim' <br /> ElI 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 Column 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. 9 LO - <br /> 4. <br /> 5.. -,� - � <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. iEnviroamental 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 --> Septemher <br /> Quarter 4 - October --> December <br /> Send to: SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E . Hazelion , P .O . Box 2009 <br /> SLockcon , CA 95201. 466-6781 <br /> UGT 40 10/86 <br /> J <br /> i <br />