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INVENTORY RECONCILIATION <br />QUARTERLY SUMMARY REPORT FORM <br />Facility Name: <br />Facility Address: <br />C4, <br />Telephone: �� �� p9g/ <br />Person Filin <br />Report cZ e,(,t 2,gs,A WTO <br />Tank <br />Size <br />Product <br />I hereby certify under pcaalty of perjury Chat all inventory variations for <br />the above mencioned facility were within the allowable Limics for this <br />quarter. (No in Column 13of the Inventory Reconciliation Sheet) <br />Inventory variations exceeded the allowable Limics for this quarter. L <br />hereby certify under penalty of perjury chat the source for the variation <br />was not due to an unauthorized (leak) release. (Yes in Colum 13 of the <br />Inventory Reconciliation Sheet) <br />List dacc,rfxok /, and amoanc for all vacinCioas Chat exceeded the <br />allowable lisiics. <br />-DaCe�.'. Tank I Amount <br />1. <br />2_ <br />J. <br />4. <br />Addicioaal daCes/amouaCs chall be continued on a separate sheet of <br />payor.and atCachcd. <br />If the .source of the variation which exceeded "allocable limits was due to <br />a Leak the incident shall be reported to S.J.L.-H.D. Environmental ileal Ui <br />W Lrhin 24 hours and an unauthorized release report submiCCed. <br />The Quarterly sus ry report shall be cubmiCced within IS days of the end of tach <br />Quarter. <br />QuarCrr I - January --) March <br />Q•iar(rr 2 - April --) J..... <br />Quarter 3 - July __) jcptcm6rr <br />Q"Ar(cr 4 - oc Cobcr --) 11.•ccmbcr <br />Send to: SAN JOAQUIN LOCA1. HEALTH 0IS'I'HICI <br />1001 1`.. I1azc I 1 nn • 1'.0 h')x 211(17 <br />SLockcon. CA '15201 1.00-67b1 <br />'.0 10/N6 <br />