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INVENTORY RECONCILIATION <br />QUARTERLY SUMMARY REPORT FORM <br />Facility Name: Fe- -� <br />Facility Address: 4io2.-Z IX6 <br />Telephone: 0 y 4s7 <br />Person Filing <br />Report '.-N- &--':3 (--( <br />• <br />Tank it Size Product <br />0 o v-� <br />3 Jilo 00c)tee. <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 />OInventory 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 />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 />4 -- <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 DIS'T'RICT <br />1601 E. Hazelton, P.O. Box 2009 <br />Stockton, CA 95201 466-6781 <br />IJGT 40 10/86 <br />E <br />0 <br />ENVIROMENTAL HEALTH <br />F EWAI T /SERVICES <br />Date <br />Tank # <br />Amount <br />2.3. <br />-�` <br />/ <br />4. <br />l - 7 <br />4.l <br />/ a <br />C _ l <br />-t-irL CC - <br />' <br />S.. <br />/— <br />s� <br />��� � <br />. <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 />4 -- <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 DIS'T'RICT <br />1601 E. Hazelton, P.O. Box 2009 <br />Stockton, CA 95201 466-6781 <br />IJGT 40 10/86 <br />E <br />0 <br />ENVIROMENTAL HEALTH <br />F EWAI T /SERVICES <br />