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INVENTORY RECONCILIATION <br /> QUARTERLY SUMMARY REPORT FORM <br /> Facility Name: LA-1 1-, S-MA 1�,5 Tank I <br /> Size Product <br /> PAC. ity Address: _1$12 W, fYjAIA) t�7: ®od EG <br /> ,Telephone : ZDy_ <br /> Person Filing <br /> Report <br /> I hereby certify under penalty of perjury that all inventoryvariations For <br /> the above mentioned facility were within the allowable lims for this <br /> quarter_ (No in Column 13of the Inventory Reconciliation Sheet) <br /> QInventory 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) release. (Yes in Column 13 of the <br /> Inventory Reconciliation Sheet) _ <br /> List date, tank #, and amount for all variatiorn that exceeded the <br /> allowable limits. <br /> Date Tank # Amount M 0p <br /> 1 . <br /> 2. <br /> j <br /> 3. <br /> 4. <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-lovable 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 <br /> quarter . IS days of the end of c.1ch <br /> Z'3 Iter 1 JaQuary --� March <br /> actcr 2 - April --> June � ��y <br /> Quarter 3 - July --> September <br /> Q'iarter 4 - October --> December <br /> Send to: SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E . Hazelton , I1 .0 . Box 2009 <br /> UCT 40 10/86 Stockton, CA 95201 466-6781 <br />