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INVENTORY RECONCILIATION <br /> QUARTERLY SUMMARY REPORT FORM <br /> Facility Name: Te-r �'S:Uuo Tank E Size Product <br /> 10,000 771 <br /> Facility Address: goo E llwy IZ <br /> _ Lew1 Cw GS-)40 6U S U- - <br /> Te lephone : (y016>4c,z- 1301 <br /> Person Filing <br /> Report S)O"'ly Foist <br /> 11/I hereby certify under penalty of perjury that all inventory variations for <br /> the above mentioned facility were within the allod.able li_ to ;cr this <br /> quarter. (No in Column 13 of the Inventory Reconciliation Sheet) <br /> E] 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 1, and amount for all variations that exceeded the <br /> allowable limits. <br /> Date Tank f Amount <br /> 1. <br /> 2. <br /> 3. <br /> 4. <br /> 5. <br /> shall be continued on a separace she-cc 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 liealth <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 /> A Quarto I - January --) March '$$ <br /> Quarter 2 - April --> June <br /> Quarter 3 - July --) Sepccmhcr <br /> Qvarccr 4 - October --) tk-cember <br /> Send co: SAN JOAQUIN LOCAL HEALTH DI:iTKICT <br /> 160 1 E . Haze I t (in , 1) . 0 . 1iox 2009 <br /> ,rcvTAL HEALTH <br /> Stockton , CA 95201 466-6781 <br /> LIt;T 40 10/ 86 l <br />