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INVENTORY RECONCILIATION <br /> i QUARTERLY SUMMARY REPORT FORM <br /> Facility Name: / k.i__ f ,+. , Tank # Size Product <br /> Facility Address: <br /> Telephone: 4?4,1,/ <br /> Person. Filln <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 /> a 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 /> 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) hodrs and an unauthorized release report submitted. <br /> `he quarterly summary report shall be submitted within fifteen (15 ) days <br /> )f the end of each quarter. <br /> Quarter 1 - January---------->March <br /> Quarter 2 - April------------>June <br /> Quarter 3 - July------------->September r 4 /0.1 <br /> QuartdOctober--------- >D&E&ffi r �R�/T/��T�� / �1 <br /> end to: SAN JOAQUIN LOCAL HEALTH DISTRICT J 'QL/CFS� �T/y <br /> 1601 E. Hazelton, P.O. Box 2009 <br /> Stockton, CA 95201 468-3420 , <br /> a <br /> H 23 019 10/86 `\� <br />