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r <br /> • • 1 <br /> INVENTORY RECONCILIATION <br /> QUARTERLY SUMMARY RFPORT FORM <br /> i �,� , <br /> Facility Name���,;i� ' /«ii C;f;,�'l-� �) IC L?icE - Tank / Size Product <br /> Facility Address: X00/ A, <br /> Telephone : a,)g - r_) <br /> Person Filing <br /> Report <br /> I hereby certify under penalty of perjury that all inventory variations for <br /> the above mentioned facility were within the allowable limits for this <br /> quarter. (No in Colusm 13of the Inventory Reconciliation Sheet) <br /> ElInventory 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) release. (Yes in Column 13 of the <br /> Inventory Reconciliation Sheet) <br /> List date, tank 1, and amount for all variations that exceeded the <br /> allowable limits. <br /> Date Tank / Amount <br /> 1. <br /> 2- <br /> 3. <br /> 4. <br /> 5. <br /> Additional dates/amounts shall be conr;_c•ied on a separate sheet of <br /> paper and attached. <br /> If 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 Health <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 --) March <br /> Qaartcr 2 - April --> June <br /> �lV Quarter 3 - July -- September <br /> carter 4 - October -- December <br /> Send to: SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E . Haze lIon , P . O . Box 2009 <br /> Stockton , CA 95201 466-6781 <br /> UGT 40 10/ 86 <br />