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r ' <br /> INVENTORY RECONCILIATION <br /> QUARTERLY SUMMARY REPORT FORM <br /> F•ciLlty. Name: {=�/p/p #ZJF, Tank I Size <br /> Product <br /> Facilit :Address: ��" )d� <br /> X2.1 y 3 h, e <br /> Telephone : c <br /> 2 n9- >V/ — 2� <br /> Person Filing <br /> Report Di'Ont, <br /> I hereby certify under penalty of perjury that all inventory variations for <br /> the above mentioned facility were vithin the allovable limits for this <br /> quarter. (No in Column 13 of the inventory Reconciliation Sheet) <br /> Inventory variations exceeded the allovable limits for :bis quarter. I � <br /> hereby certify under penalty of perjury that the source for the variation <br /> was not due to an unauthorized (leak) reles' se. (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 ; <br /> Tank f Amouat <br /> �! <br /> Z <br /> 2' Z t Z(149 J U L 1 5 1992 <br /> 3. tID& ENVIRONMENTAL. HEALTH <br /> 4. 411q Iq Z_ 1 1,-24'5- PERMIT/5LRVIG <br /> s. 41//,: <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 --) Harch <br /> QQ.1arter 2 - April --> June <br /> Quarter 3 - July --) Septcwher <br /> Quarter 4 - October --) Dc-cember <br /> Send to: SAN JOAQU IN LOCAL HEALTH DISTRICT <br /> 160 1 F. I;aze 1 <<,n , P . 0 . 1tox 2009 <br /> Stockton , CA 95201 466 -67b1 <br /> ;T 40 10/ 86 <br />