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INVENTORY RECONCILIATION <br /> QUARTERLY SUMMARY REPORT FORM <br /> Facility Name: 8 ,�'. ��>> Tank f Size Product <br /> Facility Address: '/, Al 171"1 c 2 1 s <br /> - �? <br /> Telephone : _-_-f `�� q3/-Aaro <br /> Person Filing <br /> Report { <br /> L 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. (No in Column l3 of the Inventory Reconciliation Sheet) <br /> ❑ Inventory variations exceeded the allowable limits for this quarter. T <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 f, 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 /> It 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 Ilea ith <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 --) Harch <br /> Q'}artcr 2 - April --> June a P mr <br /> Quarter 3 - July --> Scptemhr.r n <br /> Quarter 4 October --) 1}eccmbcr �+T <br /> o C I <br /> Send to: SAN JOAQUIN LOCAL HEALTH DISTP ICT ENVIRONMENTAL HEALTH <br /> 1601 f: . H ze 1 t (m , P . O . ho x 2001) €'ERPAIT/SERVICES <br /> S(ockton , CA 95201 460 -G781 <br /> I.It T 40 10/ 86 <br />