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r <br /> INVENTORY RECONCILIATION <br /> QUARTERLY- SUMMARY REPORT FORM <br /> � R <br /> Facility Name _ De ���9, "f ( ?r - Tank f Size Product <br /> Facility Address: -,�� .•fT, <br /> "Telephone : 4) 2 3 - 2 FI <br /> Person Film <br /> Re p o r t <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 Columa 13of the Inventory Reconciliation Sheet) <br /> QInventory 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 Column13 of the <br /> Inventory Reconciliation Sheet) <br /> List date, tank #, and amount for all variations that exceeded the <br /> allowable limits. <br /> Date Tank I 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 I5 days of the end of each <br /> quarter_ <br /> iter_ 1 _ ,Ianusr,y_ --) "arch <br /> QuarCer 2 April >�Jue�Quarter y <br /> Quarter 4 - October --> December <br /> Send to. SAN JOAQUIN LOCAL HEALTH DISTRICT• <br /> 1601 E . Ilaze 1 t nn , P .0 . BOx 20()9 <br /> Stockton , CA 95201 466-67bi <br /> LIG T° 140 10/86 <br />