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INVENTORY RECONCILIATION <br />QUARTERLY SUMMARY REPORT FORM <br />Facility Name: <br />Facility Address: gip / (, �P /P A <br />Telephone: <br />Person Fili g <br />Reportdti <br />Tank Size Product <br />I hereby certify under penalty of perjury that all inventory variations for <br />the above mentioned facilitywithin were wit in the allowable limits for this <br />quarter. (No 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 an unauthorized (leak) releise. (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 f 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 />Quarter 2 - April --> June <br />Quarter 3 - July --> September <br />Quarter 4 - October --> 1k'cember <br />Send to: SAN JOAQUIN IMCAL HEAL -11i DISTRICT <br />1601 P, . Hazc l Ion , P.O. hoax 2009 <br />Stockton, CA 15201 466-6781 <br />M;T 40 10/86 <br />