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INVENTORY RECONCILIATION <br /> QUARTERLY SUMMARY REPORT FORM <br /> Facility Name h ; { ���J_ ,�. Tank t Size Product <br /> Facility Address: ,ZC)0/ R' f��7 nl ✓T. <br /> Telephone : <br /> Person Filing <br /> Report ��I�C ✓. f pec ��. <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 /> 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 f Amount `��\?� <br /> 1. <br /> 2. <br /> Q `J SP�ST <br /> 3. <br /> 4. <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 - January --) March <br /> Quarter 2 - April --> June <br /> .Quarter 3 July --) Sep[cmher � <br /> Qiarter cto earmber <br /> Send to: SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E . Hazelton , P . O . Box 2009 <br /> Stockton , CA 95201 466-6781 <br /> 111;'1' 60 10/ 86 <br />