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t <br />INVENTORY RECONCILIATION <br />QUARTERLY SUMMARY REPORT FORM <br />Facility Name:'rR, A 0KS N I E, I c�Gfl a[ k <br />74cility Address <br />Telephone: c03 - G S 75- <br />Personli g <br />Report <br />MTFMW�WWWFIU��=, <br />I hereby certify unJoc penalty of perjury that all inventory variat' fot <br />the above mentioned facility were within the allowable limits for /l <br />quarter. (No in Colum 13 of the Inventory Reconciliation Sheet) OCT I <br />:! <br />V <br />Inventory variations exceeded the allowable 'limits for this quar'ii�i , <br />hereby certify -under penalty of perjury that the source For the va�lr?!nL7M <br />was not due to an unauthorised (leak) release. (Yes in Column 13 of the �Vi�rS <br />T <br />Iovontory Zsconciliation Sheet) :- <br />List date, tank fp and amount for all variations that exceeded the <br />allowable limits. <br />onto Tank i <br />1. - <br />s. - 3 <br />3. `7 -CLQ• -F1,4 <br />4. 0- �' - 3 <br />.Amount <br />i77�-�er P_eGdS <br />5 L C <br />r <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 susssary 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 DISTR�CT <br />1601 E . Haze lton , P.O. [lox 2009 <br />Stockton, CA 95201 466-6781 <br />UGT 40 10/86 <br />1) <br />