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INVENTORY RECONCILIATION <br />;UARTERLY SUMMARY REPORT O• <br />Facility Address: , <br />A <br />Telephone: .�22 gg4P <br />Person Filing <br />Report 14c) LL, <br />�w��ww■�ww�� .. <br />rw <br />�wwrrw <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. (Ho in Column 13 of the Inventory Reconciliation Sheet) <br />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 Colum 13 of the <br />Inventory Reconciliation Sheet) <br />List date, tank 1p and amount for all variations that exceeded the <br />allowable limits. <br />Date Tank # Amount <br />X139 <br />s. -® 2 <br />4. 17 �? <br />5.. 1t -L21®2 -� <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 I - January March <br />Quarter 2 - April --> June <br />k <br />Quarter 3 - July --> Scptcmher <br />Quarter 4 - October --> December <br />Send to: SAN JOAQUIN LOCAL. HEALTH DISTRICT <br />1601 E. Hazelton, 1' .0 . Box 2009 <br />Stockton, CA 95201. 466-6781 <br />UCT 40 10/86 <br />s <br />R <br />