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AM PM #2186 Pg 1G y <br /> 3212 N. CALIFORNIA ST; <br /> FON; CA 95204 <br /> INVENTORY RECONCILIATION <br /> QUARTERLY SUMMARY REPORT FORM <br /> Facility. Names �2i � rank Stze <br /> Product <br /> FAcilitAddress: <br /> c <br /> Telephone : /- ,og gVi_ z2 <br /> Person Filing <br /> Report <br /> E] 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 Column 13 of the Inventory Reconciliation Sheet) <br /> ElInventory 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 f, and amount for all variations that exceeded the <br /> allowable limits. <br /> Date Tank E Amount <br /> 1. <br /> 2. -IS--3 <br /> 3. <br /> gj- <br /> 4. /k Ai / 1-/Z-2- <br /> 5. f/C <br /> Additional dates/amounts shall be continued on a separate sheet of <br /> paper and attached. <br /> If the source of the variation whichexceeded 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 /> Qlarter 1 - April --) June <br /> Quarter 3 - July --> September <br /> Quarter 4 - October --> (kcember <br /> Send to: SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 160L E. Haze 1 <<�n . P . O . Rox 2009 <br /> Stockton .- CA 95201 466 -6781 <br />::T 40 10/86 <br />