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VENTORY RECONCILIATION <br />QUARTERLY SUMMARY REPORT FORM <br />Facility llama: DICK'S Ad PM <br />25775 S. P$tWM FM <br />Facility Address: They, CA. 95376 <br />Telephone: <br />Person Filing <br />Report <br />i <br />Tank # Size Product <br />I hereby certify under penalty of perjury that all inventory variations for <br />the above mentioaad facility were within the allowable limits for this <br />quarter. (No in Colum 13 of the Inventory Reconciliation Sheet) <br />Q laveatory variatio" exceeded the allowable limits for this quarter. I <br />hereby certify under penalty of perjury that the source for the variatioa <br />was amt due to &a wouthorized (leak) release. (Yes in Column U of the <br />Inve:atory Reconciliation Sheet) <br />List date, tank #, and amount for all variations that exceeded the <br />allowable limits. <br />Date Tank � Amount i a 11 <br />2. <br />3. <br />4. <br />A?1JEItVIt,r"� <br />S. <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 -- 6') WT <br />4CL rter 2 - April --> June <br />Quarter 3 - July --) September <br />Quarter 4 - October --> December ' <br />.. s+ <br />Send to: SAN JOAQUIN LOCAL HEALTH DISTRICT !� ° <br />1601 E. Hazelton, P.O. Box 2009 <br />Stockton, CA 95201 466-6781 <br />UCT 40 10/86 <br />