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INVENTORY RECONCILIATION <br /> QUARTERLY SUMMARY REPORT FORM <br /> Facility Name��`�%iZ-�� �c�-r�L�;�,,L <br /> Tank. # size Product <br /> Facility Address: ,/. ✓� <br /> - <br /> 'Te1ephone <br /> Person Filing <br /> Re p o r t <br /> y <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 13 of 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 #, and amount for all variations that exceeded the <br /> allowable limits_. <br /> Date 'lank Amount <br /> 1- <br /> 2. <br /> 3- <br /> 4. <br /> S. <br /> Additional dates/amounts shall be continued on a separate sheet of <br /> paper and attached. <br /> If the source of the variation which. erceeded 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 I - January --) March <br /> Quar er - April --> -lune <br /> Quarter 3 - July --) September <br /> Quarter 4 - October --) December <br /> Send to: SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E . tele 1 s_0n , P .O . fro,\ 2()()9 <br /> SCockton , CA 95201 460-6781 <br /> 19 "T 40 10/ 86 <br />