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INVENTORY RECONCILIATION <br />QUARTERLY SUMMARY REPORT FORM <br />Facility Name: J ►Maw <br />Facility Address: 351 K 1. <br />_e-tti I Co <br />Telephone: <br />Person Filing <br />Report <br />Tank # <br />Size <br />Product <br />3 <br />i a, - <br />VAAL . <br />izAW. <br />, <br />/44M <br />U <br />!v <br />12 -el <br />1 hereby certify under,peoalty 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 />was not due to an unauthorized (leak) releise. (Yes in Column* of the <br />Inventory Reconciliation Sheet) <br />List date, tank i, and amount for all variations that exceeded the <br />allowable lionits. <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 at-lowable 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 I - January --) March <br />Quarter 2 - ApriL --> June <br />Quarter 3 - July --> Septemh4-r <br />Q%jarter 4 - October --) Ikcember <br />Send to: SAN JOAQUIN LOCAL HEALTH DISTRICT <br />1601 E. !laze 1 to►n , P.O. Box 2009 <br />Stockton, CA 95201 466-6781 <br />UCT 40 10/86 <br />