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INVENTORY RECONCILIATION <br /> QUARTERLY SUMMARY REPORT FORM CMont6-1rva ct�t✓t�Ctkw <br /> Facility Name: til kto• (�h.fi FgCif 1"ie Tank # Size J Product <br /> Facility Address : 193.1 N, F-L. P„.a� Dr Q <br /> -H <br /> Telephone: C?,44 • 07 <br /> Person Filing <br /> Report: . Fra,-\K A,. <br /> I hereby certify under penalty of perjury that all inventory variations <br /> ❑ for the above mentioned facility were within the allowable limits for <br /> this quarter . (No in Column 13 of the Inventory Reconciliation Sheet. ) <br /> Inventory variations exceeded the allowable limits for this quarter. I <br /> a hereby certify under penalty of perjury that the source for the varia- <br /> tion was not due to unauthorized ( leak) release. (Yes in Column 13 of <br /> the Inventory Reconciliation Sheet) . <br /> List date, tank # , and amount for all variations that exceeded <br /> the allowable limits . <br /> Date Tank # Amount <br /> 1 . 1 - )C)-- ciO 80oo 310"18 rt 5 <br /> 2 . k-)_ -90 -52.8 - 14CW11 e, <br /> 3 . i - 31 - 9D -4_ 9..9), s <br /> 4 . .+ &i • 3 ggl�oh5 <br /> 5 . - le)~ yD <br /> --t-81. I " 1 OAS <br /> Additional dates/amounts shall be continued on a separate sheet <br /> paper and attached. <br /> If the source of the variation which exceeded allowable limits was <br /> due to a leak, the incident shall be reported to San Joaquin Local <br /> Health District; Environmental Health Division, within twenty-four <br /> ( 24 ) hours and an unauthorized release report submitted. <br /> The quarterly summary report shall be submitted within fifteen (15 ) days <br /> of the end of each quarter. <br /> Quarter 1 - January----------->March <br /> Quarter 2 - April------------>June <br /> Quarter 3 - July------------->September <br /> Quarter 4 - October---------->December <br /> Send to: SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. Hazelton, P.O. Box 2009 <br /> Stockton, CA 95201 468-3420 <br /> EII 23 019 10/86 <br />