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h <br /> INVENTORY RECONCILIATION <br /> QUARTERLY SUMMARY REPORT FORM <br /> Facility Haase: %7—/ /��;, I ' �j✓i" Wank # <br /> Size Product <br /> Facility Address: <br /> ✓ '"C --Z2, - <br /> Telephone : 3 <br /> Person Filing <br /> Report <br /> ElI 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. (Ko in Columa 13 of the Inventory Reconciliation Sheet) <br /> ElInventory variations exceeded the allowable limits for this quarter. I <br /> hereby certify under penalty of perjury that the source for the variation <br /> vas not due to an unauthorized (leak) rele"e. (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 I Amount <br /> 1. � <br /> 2. <br /> 3. APR 0 6 1987 <br /> 4. <br /> ENVIROMENTAL HEALTH 5. PERMIT/SERVICES <br /> Additional dates/amount:s shall be continued on a separate sheet of <br /> paper and attached. <br /> If the source of [he variation ahich. exceeded allowable limits was due to <br /> a leak the incident shall be reported to EnvironentaL health <br /> Within 24 hours and an unauthorized release report sm <br /> submitted. <br /> The quarterly summary report shall be submitted within IS days of the end of each <br /> quarter. <br /> Quarter I - .January -- <br /> Quarter 3 - July --) -;eptcmbcr <br /> Quarter 4 - October --) t�cember <br /> Send to: SAN JOAQUIN 1,0(,AL HEALTH DISTRICT <br /> 1601 I-; . k"arcs l l am , p . O . Jinx 20O°} <br /> SLockr-on , CA 95201 466 -67h1 <br />