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INVENTORY RECONCILIATION <br />QUARTERLY SUMMARY REPORT FORM <br />Facility Name: VAL4oC; �,�t6���,� <br />HMO— <br />Facility Address: <br />AW <br />Telephone: Q'3 /r / <br />Person F lin <br />Tank # Size Product <br />L hereby certify under penalty of perjury that all inventory variations for <br />"he above mentioned facility were within the allowable lilwitz for thi= <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 coder penalty of perjury that the source for the variation <br />vas not due to an unauthorized (leak) release. (Yes in Column 13 of the <br />Inventory Reconciliation Sheet) t <br />List date, tack 1, and amount for all variations that exceeded the <br />allowable Limits. <br />Date Tank f Amount <br />z. APS 1 <br />3. ENVIROMENTAL HEALTH <br />4. FERMIVSERVICES <br />5_ <br />Additional dates/amounts shall be continued on x separate sheet of <br />paper and attached. <br />Lf the source of the variation whichexceeded at-lowable 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 />1ht quarterly summary report shall be Aubmitted within 15 days of the end of each <br />Quarter. <br />Quarter i - January March <br />Qlarter 2 - April --) June <br />Quarter 3 - July --> Septemhcr <br />Quarter 4 - October --> December <br />Send' to: < ;" SAN : JOAQUI` (1f =oHE <br />ALT1i 'DI'STRiC�i <br />1601 L. Hazel ton , P , 0 , tiny 2009 <br />Stockton, CA 95201 466-6761 <br />. Lk -l" 140:• 10./8b :...- <br />