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INVENTORY RECONCILIATION <br /> QUARTERLY SUMMARY REPORT FORM <br /> r" <br /> Facility Name: �~ s 'r Tank 4 Size Product <br /> Facility Address :; <br /> Telephone: <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. <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 . �� 9 G. <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 /> 'he gdartealy summary report shall be submitted within fifteen ( 15 ) days <br /> if the end of each quarter. <br /> ti <br /> Quarter 1 - Januar ` <br /> Quarter 2 - April------------>June Np�ro,SAN <br /> Quarter 3 - Jul <br /> rtt�- October---------- � <br /> ___ ----- <br /> Y-------- >September <br /> .tea' >l'7•�t-em er <br /> end to: SAN JOAQUIN LOCAL HEALTH <br /> 1601 E. Hazelton, P.O. Sox 2009 <br /> Stockton, CA 95201 468-3420 . <br /> R <br /> H 23 019 10/86 <br />