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INVENTORY RECONCILIATION Ai <br />QUARTERLY SUMMARY REPORT FORM ENVIRU:v;E;vfAL HEALTH <br />PPPMIT/SERVICES. <br />Facility Name: %2�,_, (�� C '. =C=� 3 <br />o2Z Aiw% /.Z60 <br />Facility Address: aD ? "a- 0. Y,O't v..-1.44 4-)-± <br />Nu, -t4 -9-c, ' Q� q 3 36, <br />Telephone: © 5 - -z--5 Ci S - z 3— <br />Person Filin!=-Cogt, <br />Report l�•-t ���_ <br />Tank # <br />SizeProduct <br />/ <br />i� <br />A4-1 <br />l0 vim' k <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 />E] 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 />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 Uealth <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 --> September <br />Quarter 4 - October December <br />Send to: SAN JOAQUIN LOCAL HEALTH DISTRICT <br />1601 E. Ilaze lion , 1' . 0 . Box 2009 <br />Stockton, CA 95201. 466-6781 <br />UGT 40 10/86 <br />