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INVENTORY RECONCILIATION <br /> QUARTERLY SUMMARY REPORT FORM <br /> Facility Namc: Tank # Size Product <br /> __ O000 <br /> Facility Address : .1 <br /> Telephone: Q <br /> 11-71 <br /> Person, Filing <br /> Report:: <br /> I hereby certify under penalty of perjury that -all inventory variation: <br /> for the above mentioned facility were within the allowable limits for <br /> this quarter. (No in Column 13 of the Inventory Reconciliation Sheet. ; <br /> Inventory variations exceeded the allowable limits for this quarter. 7 <br /> F1 <br /> hereby certify under penalty of perjury that the source for the varia- <br /> tion was not due to unauthorized ( leak) release. (Yes in Column 13 of <br /> the Inventory Reconciliation Sheet) . <br /> List date, tank # , and amount for all variations that exceeded <br /> the allowable limits. <br /> Date Tank # Amount <br /> 1. <br /> 2. <br /> 3. <br /> 4 . <br /> 5. <br /> Additional dates/amounts shall be continued on a separate sheet <br /> paper and attached. <br /> If the source of the variation which exceeded allowable limits was <br /> due to a leak, the incident shall be reported to San Joaquin Local <br /> Health District; Environmental Health Division, within twenty-four <br /> (24 ) hours and an unauthorized release report submitted. <br /> The gdartgrly summary report shall be submitted within fifteen (15 ) days <br /> of the end of each quarter. <br /> Quarterl - January-- >March <br /> Quarter 2 - April------------ <br /> Quarter 3 - July------------->September <br /> Quarter 4 - October---------->December <br /> Send to: SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. Hazelton, P.O. Box 2009 <br /> Stockton, CA 95201 468-3420 , <br /> e <br /> ,1] 23 019 10/86 <br />