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INVENTORY RECONCILIATION <br />QUARTERLY SUMMARY REPORT FORM <br />Facility. Names Wal Alike <br />F:ciist Adaca:.s tt °", CA 9520T ,',42.rZ,'� <br /># 2- <br />Telephone: y2 YSS-Sr2 <br />Person Filin,,$$-� <br />Report <br />Tank I Size Product <br />d ` 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 It and amount for all variations that exceeded the <br />allowable limits. <br />Date Tank 0 Amount <br />1. <br />2. <br />3. <br />4. <br />s. <br />J U L 0 6 1992 <br />ENVIRONMENTAL HEALTF <br />PERM ITMERVim, <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 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 1 - January --> March <br />la er - April -- une <br />Quarter 3 - July --> September <br />Quarter 4 - October --> Ikcember <br />Send to: SAN JOAQUIN LOCAL HEALTH DISTRICT <br />1601 E. I:aze I t o n, 11.0. Box 2009 <br />Stockton, CA 95201 466-6781 <br />:ICT 40 10/86 <br />