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INVENTORY RECONCILIATION <br /> QUARTERLY SUMMARY REPORT FORM <br /> Facility Name: QW S'TbA 125 Tank I <br /> Size Product <br /> Fac. ity Address: ��' �� IWAA) -r s ®®6 �G <br /> Telephone : Ze�y- 549- X25! <br /> Person Filing _ <br /> Report L� <br /> L hereby certify under penalty of perjury that all inventoryvaria <br /> ti <br /> the above mentioned facility were within the allowable lims forthis$ for <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) release. (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 I 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 /> Quarter I - January --> March <br /> Quarter 2 - April --> June �Ci <br /> Quarter 3 - July --> September <br /> ,actcc - October --> December <br /> .,end to: SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. liazelton , P .O . Box 2009 <br /> 11CT 40 10/86 Stockton, CA 95201 466-6781 <br />