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3 i <br />INVENTORY RECONCILIATION �H.? <br />QUARTERLY SUMMARY REPORT FORM i�1�VIRC'"i -; <br />I <br />w RL HcALTH <br />,j F ER.M1 i-; sERVICES <br />Facility Name:) <br />_ Im <br />Facility Address: -351 to i &A-MRa <br />CA- y�c� <br />Telephone : �j 3{��;�� %-17 <br />Person Filin ,/,) <br />Re p o r t I CC -K <br />Tank # <br />Size Product <br />S:, <br />M <br />°S <br />keycsrL" <br />W <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 to an unauthorized (leak) releise. (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 each <br />Quarter. <br />art <br />i - January --) ka�c-fi <br />Quarter 2 - Apri -- une <br />Quarter 3 - July --> Septemh4-r <br />QQiarter 4 - October --> D%-cember <br />Send to: SAN JOAQUIN LOCAL HEALTH DISTRICT <br />1601 E. Haze 1 <<►n , P.O. BoX 2009 <br />Stockton, CA <br />95201 466-67bl <br />U(,'1' 40 10/86 <br />