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Vim' 1 <br /> INVENTORY RECONCILIATION <br /> QUARTERLY SUMMARY REPORT FORM <br />/FacilityNameTank 1 Size Product <br /> Facility Address: �?C)0Z R' <br /> Telephone r_� <br /> Person Filing <br /> Report:ca �tiia,dC Tr.'s cG <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 Column 13of the inventory Reconciliation Sheet) <br /> Inventory 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 continued 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 - Jaouary --) March <br /> �a-r-C-C-C <br /> Quarter 3 July --) September t� <br /> �Y— Qiartcr - 6c[obcr --> Ikccmbcr <br /> Send to: SAN JOAQUIN LOCAL HEALTH DISTRICP <br /> L601 E . Haze 1 i on , P . 0 . llox 2009 <br /> Stockton , CA 95201 466 -67bl <br /> U(;T 40 10/ 86 <br />