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ION 11 <br /> INVENTORY RECONCILIATION <br /> QUARTERLY SUMMARY REPORT FORM <br /> Facility Name: , [y' Tank # Size Product <br /> Facility Address : <br /> 9 Telephone: <br /> Person. Filing <br /> Report:, r <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. ] <br /> reby certify under penalty of perjury that the source for the varia- <br /> tion was nor 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 . /d <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 gdarterly summary report shall be submitted ,.6 thin fifteen ( 15 ) days <br /> of the end_ of each quarter. <br /> Quarter 1 - January---------->Ma ��� ��/� " <br /> Quarter 2 - April------------>June ' ' <br /> Quarter 3 - July---------.---->Sc tember <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 /> EH 23 019 10/86 V <br />