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r <br /> M <br /> e <br /> t , <br /> 0 <br /> INVENTORY RECONCILIATION <br /> QUARTERLY SUMMARY REPORT FORM <br /> Facility Name : 1ev -4 2 2 <br /> Tank # Size Product <br /> Facility Address :-Ltioa DavinLAddress:- Dr. ( 101000 <br /> 2 10 000 pv'c-n-1 <br /> Telephone :— 20q 452-�YD-45 10 o0c) Ll WaLked <br /> Person Filing <br /> Report : biwa ( <br /> [ ] I Hereby certify under penalty of perjury that all inventory <br /> variations for the above mentioned facility were within the allowable <br /> limits for this quarter. (No in Column 13 of the Inventory <br /> Reconciliation Sheet ) . <br /> [Inventory variations exceeded the allowable limits for this quarter. <br /> I hereby certify under penalty of perjury that the source for the <br /> variation was not due to an unauthorized ( leak) release. (Yes in <br /> Column 13 of the Inventory Reconciliation Sheet ) . <br /> k5F <br /> List date, tank # , and amount for all variations tha eced .ahe <br /> allowable limits . <br /> T4, <br /> .r, a <br /> JAN 1 6 <br /> f i <br /> Date Tank # Amount <br /> 4 I u�mi°9���Cs' 1�! f <br /> 1• �4 �ilvra < s'a� s <br /> 1P A <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 <br /> to a leak the incident shall be reported to S.J.L.H.D. Environmental <br /> Health within 24.-.hours and an unauthorized release report submitted. <br /> The quarterly summary report shall be submitted within 15 days of the <br /> end of each 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 DISTRICT <br /> 1601 E. Hazelton, P. 0. Box 2009 <br /> Stockton, CA 95201 466-6781 <br /> T 40 10/86 <br />