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INVENTORY RECONCILIATION <br /> QUARTERLY SUMMARY REPORT FORM <br /> Facility Name 67,),_:- Tank f size Product <br /> Facility Address: �,�()/ �f�,tJ h-, <br /> 'Telephone : c429 - JU 3 -26, -/ _ <br /> Person Film <br /> Report 1 <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 /> 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 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 Tank I Amount <br /> #. <br /> Z. <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 ,,T ,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 1 - January --> March <br /> Quarte r 7 ___- _Ap.ril- <br /> ^Quarter 3 - July --> September <br /> Send to_ SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E . fuze 1 t-on , P . O . BOX 2009 <br /> Stockton , CA 95201 460-6781 <br /> t1GT 40 10/ 86 <br />