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0 <br /> INVENTORY RECONCILIATION RECEIVED, <br /> QUARTERLY SUMMARY REPORT FORM JUL 0 1 <br /> _ PNVIRpI MENT4 HF�,�-Tri <br /> Facility Name: % _ wG Tank F - roduct <br /> Facility Address: yy �' <br /> - Lc� C'q - sem _ r• <br /> Telephone : q_7i-Zooo r <br /> Person Filing <br /> Report ,,, <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. (Ho 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 as unauthorized (leak) release. (Yes in Coleman13 of the <br /> Inventory Reconciliation Sheet) <br /> List date, tank f, sad amount for all variations that exceeded the <br /> allowable limits. <br /> Date Tank f Amount <br /> 1. <br /> 2. <br /> 3_ <br /> 4. <br /> S. <br /> Additional dates/amouats 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 Fubmitted within 15 days of the end of each <br /> quarter. <br /> Quarter I - January --? Hardy <br /> Q1arcer 2 - April --> Junv <br /> Quarter 3 - itity September <br /> Qjarter 4 - October T> ikc(•mt)er <br /> Send to: SAPS JOAQU IN 1.0CAI, HEALTH DISTRICT <br /> 1601 E , Haze 1ion , I' - U . Box Zt09 <br /> Stockton , CA 95101 466 -67bI <br /> U(;T 40 10/80 <br />