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INVENTORY RECONCILIATION JAN 1 QJ <br /> QUARTERLY SUMMARY REPORT FORM ENVIRONI ENIALHEALT1- <br /> _PERMIT/SLRVICES <br /> FaciLitF Names i l/ly,. I$(o 'tank i S. <br /> Product <br /> I U <br /> FaciI�ec )I- <br /> 00c,X11 i\� . ( �: ;r-ni d IC �`t�c <br /> 5 C-A t�, c k Fc, `►-� a <br /> Telephone : _i G <br /> 7q <br /> Person Filing <br /> n <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 /> Inventory variations exceeded the allovable limits for this quarter. I <br /> hereby certify under penalty of perjury that the source for the variation <br /> was not due to ao 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 f Amount <br /> 1. to <br /> Z. 10 4 2o,2- <br /> 3. lo)y 1 - 40 <br /> 4. )o 15 +_4cko <br /> 5. 1C <br /> Additional dates/amounts shall be continued on a separate sheet of <br /> paper and attached. <br /> If the source of the variation which. erceeded 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 --) Narch <br /> Quarter 2 - April --> June <br /> Quarter 3 - July --> September <br /> Quarter 4 - October --) December <br /> Send to: SAN JOAQU IN LOCAL HEALTH DISTRICT <br /> 160L E . Itar.c 1 t ��,� , P . O . It<�x 2009 <br /> SLOckton , CA 95201 466 -6781 <br /> ICT 40 10/ 86 <br />