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I <br />INVENTORY RECONCILIATION <br />QUARTERLY SUMMARY REPORT FORM <br />LIP <br />Facility Name: rp" Vii) K S �?�vF �S J --r)04) 1' j4PJ-# j Tank 1� <br />Facility Address: 4qo IV, M/� <br />Lla&4-P r �; (' A cA 53 U� <br />Telephone:- c-) 3Q - 5"7S <br />Personling <br />Report )n ., .riQ <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 13of 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 dates tank #, and amount for all variations that exceeded the <br />allowable limits.Ov <br />Orate r" Tank* G ' ,Amount <br />go _95 <br />s. <br />3• _..� �C9 <br />i <br />4. -)-19 ;Le's <br />.Additional dates/amounts shall be continued on a separate sheet of <br />paper and attached. <br />�.fi <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"4 <br />,. quarter. <br />Quarter 1 - January --> !larch <br />Quarter 2 - April --> June <br />L} <br />Quarter 3 - July --> September <br />Quarter 4 - October --> December <br />SAN JOAQUIN LOCAL. HEALTH DISTINCT <br />a <br />1601 E. Hazelton, P.O. Box 2009 <br />Stockton, CA 95201 466-6781 <br />