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INVENTORY RECONCILIATION <br />QUARTERLY SUMMARY REPORT FORM <br />Facility Name:I-_,qA,,,,l <br />Facility Address: 6.5E -IL -C- AvE <br />;V ._._.. <br />Telephone: C sq - 95 7� <br />Person T07a-ilp <br />ing <br />Report 441c� Q..2. <br />t Tank f I Size I Product I <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 />�j Inventory variations exceeded the allowable'limits for this quarter. I <br />7T 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 #, and amount for all variations that exceeded the <br />allowable limits. <br />Date Tank # Amount <br />2. <br />3. 1- '7. % <br />4. 1 - VI - 9r) l lesl <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 />Quarter 2 - April --> June <br />Quarter 3 - July --> Septemher <br />Quarter 4 - October December <br />Send to: SAN JOAQUIN LOCAL. HEALTH DISTR,, CT <br />1601 E. l:azelton, P.O. Box 2009 <br />Stockton, CA 95201. 466-6781 <br />UGT 40 10/86 <br />0 <br />