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A <br />• <br />INVENTORY RECONCILIATION D � e <br />QUARTERLY SUMMARY REPORT <br />Facility Name: � /lug � <br />Facility Address:'Yv - <br />Telephone: '�-2c4 <br />Person Filing <br />Report <br />FORMJA <br />�• <br />0 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 />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 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. 5 - 1, f 7Y IS 1��ur�i <br />4. lam- y- Ssk l l� <br />5.. <br />Additional dates/amounts shallbe 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 ?larch <br />Quarter 2 - April --> June <br />Quarter 3 - July --> September <br />Quarter 4 - October --> December <br />Send to: SAN JOAQUIN LOCAL. HEALTH DISTR\.CT <br />1601 E. Hazelton, 1' .0 . Box 2009 <br />Stockton, CA 95201. 466-6781 <br />UGT 40 10/86 <br />