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y <br /> INVENTORY RECONCILIATION <br /> QUARTERLY SUMMARY REPORT FORM <br /> Facility Name: _QLA-Ii< S-z-p,p 12 Tank I <br /> Size Product <br /> Fac. icy Address: /5 j �� �i� �'r 0Dp EG <br /> )1 ADAJ CA 95.36 6 <br /> -Telephone : may_ $-9q_ 2.2.5"/ <br /> Person Filing <br /> Report <br /> I hereby certify under Penalty ofer'urya <br /> t all ti <br /> the above mentioned facility were within theallowableelimitsvfor athiss for <br /> Quarter. (No in Column 13 of 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 variations that exceeded the <br /> allowable limits. <br /> Date Tank # Amount <br /> 1 . <br /> 2. <br /> 3. <br /> 4. <br /> S. <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 Elealth <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 rnd of each <br /> Quarter I - January --) March <br /> Darter - April --> June (G <br /> Nniarter 3 - July --> Septemhr_r l 1 <br /> Qtiarter 4 - October --> December <br /> 'en`s to: SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. Hazelton , P . O . Box 2009 <br /> UCT 40 10/86 Stockton, CA 95201 466-6781 <br />