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f o� wa,�r .-, ,�a�1�✓� /2, 3l- ee <br /> INVENTORY RECONCILIATION ' {� <br /> QUARTERLY SUMMARY REPORT FORM <br /> Facility Name: / / 7 W// - Tank I Size. Product <br /> llacility,Address: / S „040 4107 u_Fc -- �• C L; <br /> r A C�Z7!7_--3 7 <br /> �- <br /> _-Telephone : 20g - e3 —'Q-770 <br /> -- <br /> Person Filing, - <br /> Report L,'�✓ lCmr���1� <br /> 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 /> QInventory 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 E Amount <br /> 1. <br /> 2. <br /> 3. <br /> 4. <br /> S. <br /> Additional dates/amounts shall be continued on a separate sheet of <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 Lica 1 th <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 --) Scptemhcr <br /> Quarter 4 - October --> Ikcembec <br /> send co: SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E . Haze l t oii . P .O . Box 2009 <br /> Stockton , CA 95201 466-6761 <br /> LIGT 40 10/86 <br />