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INVENTORY RECONCILIATION <br /> QUARTERLY SUMMARY REPORT FORM <br /> lEaciLity. Nam: _ {�lYl Ply) Zlro Tank Size. <br /> Product <br /> / _ 7 <br /> �aciticy:/Wdre.s: 3�z �✓, CI►I,firn ; a . Jo <br /> -- lOct-40n CA <br /> n <br /> Telephone : 2o9 - 174//_ Z(p 9 4/- <br /> Person Filing <br /> Report <br /> WIThereby certify under penalty of perjury that all inventoryvariations <br /> the above mentioned facility were within the allowable limfor <br /> fo. th;2 E c <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 /> vas not due to an unauthorized (leak) releise. (Yes in Column 13 of the <br /> Inventory Reconciliation Sheet) <br /> List date, tank f, and amount for all variations that exceeded the <br /> allowable limits. <br /> Date Tank E Amount <br /> 1. '7 / �F-3 <br /> 2. Z J 4 /22- <br /> 3. <br /> /22- <br /> 3. �i - / -V-J Af <br /> 4. 913 _ + o L4 <br /> s. g y gy <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 > Septemhr.r <br /> Quarter 4 - October --> [kcember <br /> Send to: SAN JOAQU IN LOCAL HEALTIi DISTRICT <br /> 160L E . Itaze 1 C c►n . P .O . Box 2009 <br /> SLockton .- CA 95201 466-67bl <br /> CT 40 10/86 - <br />