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i <br />i' <br />IIli <br />1 <br />'I)V5 INVENTORY RECONCILIATION <br />L� <br />QUARTERLY SUMMARY REPORT FORM <br />Facility Name: <br />Facility Addrei <br />/ZAyK5 Anjr- STG7�OC�%)�Al�T% <br />8 <br />Tank # Size Product <br />s s � - I A r� ��r, <br />- A <br />r - <br />- <br />Telephone: <br />Person F in r) <br />Report `Y , A <br />I hereby certify under penalty of perjury that all inventory variations for <br />the above mentioned facility were within the allowable t F�ap� <br />quarter. (No in Column 13 of the Inventory Reconciliat el <br />JAN $ <br />Inventory variations exceeded the allowable'limits for this quart'eF. TH <br />hereby certify under penalty of perjury that the souJk i&4N&'��'`ott°` <br />was not due to an unauthorized (leak) release. (Yes inI�dnil3i�'e�-� <br />Inventory Reconciliation Sheet) <br />List dates tank #, and amount for all variations that exceeded the <br />allowable limits. <br />Date Tank # <br />2. -� �- 3 <br />3. /r� —.. —�� 9 �3 <br />4. _h `3 <br />S.. L 1 —F9 13 <br />Amount m Ty- P, EA V S <br />Lc7t�Cn0 M E /ilk t tl1tC <br />�L7.SG� w °+E'ki UO L U rn /l l iia A/< ye7 S (C>W . <br />,y inE-T�2 R,�ADS tvk�Gc�raF�Rr�j� <br />"A -5 ,04E4 VC>LumE /tiJ '7_.-1A)tIGCTSL0k) <br />gg1J � S Lo(-�J) , <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 --> September <br />Quarter 4 - October --> December <br />Send to: SAN JOAQUIN LOCAL. HEALTH DISTR1 CT <br />1601 E. Hazelton, N.O. Box 2009 <br />Stockton, CA 95201 466-6781 <br />UGT 40 10/86 <br />f <br />I <br />