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INVENTORY RECONCILIATION <br />QUARTERLY SUMMARY REPORT FORM i <br />T ` 9�9 (U/ <br />Facility Name: VV1Uut Cep CXvr4\ <br />Facility Address: <br />�c 33 <br />Telephone: 2-04,- gtA3- 20s N <br />Person Fil' <br />Report Q��c 1A \,,4 v_ke- <br />' •' <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 />Inventory variations exceeded the allowable limits for this quarter. I <br />hereby certify under penalty of perjury that the source for the variation <br />vas not due town unauthorized (leak) release. (Yes in Column 13 of the <br />Inventory Reconciliation Sheet) <br />List date, tank 1, and amount for all variations that exceeded the <br />allowable limits. <br />Date Tank f Amount <br />1. <br />2. <br />3. <br />4. <br />5. <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 cacti <br />- quarter. t <br />�r2 <br />January --> March 1 C\ <br />.1 te- April --> June <br />Quarter 3 - July --> September <br />Quarter 4 - October --> December <br />Send to: SAN JOAQUIN LOCAL HEALTH DISTRICT <br />1601 L . raze lt.on , P.O. Box 2009 <br />Stockton, CA 95201. 466-6781 <br />UGT 40 10/86 0uV` VV�q���� q�a,T�Ss COPY <br />a� ck V�" 04 <br />51M*)Vov\ C q <br />