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N so <br />INVENTORY RECONCILIATION <br />QUARTERLY SUMMARY REPORT FORM <br />Facility Name: J iw1 0 i� <br />Facility Address: _ 39 <br />Lt -"OC I (LA, <br />Telephone: (&",) 3ES t-1 s' <br />Person Filing nn � <br />Report LaA ► ►�6Y� <br />0 <br />T G 1 1987 <br />ENVIROMENTAL HEALTH <br />PERMIT /SERVICES <br />Tank Size Product <br />sr - <br />o J T <br />gm <br />C Y C <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 />ElInventory 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 to an unauthorized (leak) releise. (Yes in Column 13 of the <br />Inventory Reconciliation Sheet) <br />List date, tank t, and amount for all variations that exceeded the <br />allowable Limits. <br />Date Tank # Amount <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 each <br />Quarter. <br />Quarter I - January --> March <br />Quarte = April --> June <br />Quartet 3, July --> Septemhcr <br />Quarter 4 - October --> [kcember <br />Send to: SAN JOAQUIN LOCAL HEALTH DISTRICT <br />1601 E. Haze1Loll. P.O. Box 2009 <br />Stockton, CA 95201 466-6781 <br />W;1- 40 10/86 <br />