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RECEIVEp <br /> � � <br /> INVENTORY RECONCILIATION POR JA199 <br /> N j F <br /> QUARTERLY SUMMARY REPORT FORM M� / k '( '4f r'' <br /> FacWty. Hames z1 eTank f Size <br /> Product <br /> Facilitr:Addre••s .Z/z. �✓ Com./ � �o Uoo ,� <br /> .S/ 1„ o 00 <br /> for CA qt;-2D'/ <br /> Telephone : 1:26)c/) -2- <br /> c <br /> Person Filin <br /> Report otZnnl S �✓;/A- <br /> 0 I hereby certify under penalty of perjury that all inventory variations for <br /> the above mentioned facility were within the allowable H sitz Ear t:ia <br /> ivarter. (No in Column 13 of the Inventory Reconciliation Sheet) <br /> U 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 I, and amount for all variations that exceeded the <br /> allowable limits. <br /> Date <br /> Tank E Amount <br /> 1. <br /> i. C)15 az — ] g <br /> 3- �� s c Z ► _— 11 1 <br /> 4. Ly7 <br /> 5. �o I IT C1 Z- 1 — I <br /> Additional d,ate•/aw--ants shah be c..;:ia..z.-'. ca a aepz ate sheet 0, <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 --> September <br /> Quarter 4 - Octobcr --) lkcember <br /> Send to: SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 160L E . haze 1 torn . P . 0 . Box 2009 <br /> SLockton .- CA 95201 466 -6781 <br />::T 40 10/ 86 <br />