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INVENTORY RECONCILIATION <br /> QUARTERLY SUMMARY REPORT FORM <br /> Facility Name : S-g <br /> Tank f Size Product <br /> Facility Address : y$5 W• 6/xwrLIHE , /Oo� RE (6 <br /> IPActi Cal:� ,J <br /> Telephone : Y3,5- Qa5� <br /> Person Filing <br /> Report : 9,L Ps n3A <br /> [ ] I Hereby certify under penalty of perjury that all inventory <br /> variations for the above mentioned facility were within the allowable <br /> limits for this quarter. (No in Column 13 of the Inventory <br /> Reconciliation Sheet ) . <br /> �(] Inventory variations exceeded the allowable limits for this quarter. <br /> ► ` I hereby certify under penalty of perjury that the source for the <br /> variation was not due to an unauthorized ( leak) release . ( Yes in <br /> Column 13 of the Inventory Reconciliation Sheet ) . <br /> List date, tank # , and amount for all variations that exceeded the <br /> allowable limits . <br /> Date Tank R Amount <br /> 1. <br /> 2. <br /> 3 <br /> 4 . <br /> Gni 1 � 19 <br /> 5 . <br /> Additional dates/amounts shall be continued on 'a segara ' sheet of <br /> paper and attached. <br /> If the source of the variation which exceeded allowable limits was due <br /> to a leak the incident shall be reported to S .J.L.H.D. Environmental <br /> Health within 24"•-hours and an unauthorized release report submitted. <br /> The quarterly summary report shall be submitted within 15 days of the <br /> end of each quarter. ^, <br /> Quarter 1 - January --> March <br /> Quarter 2 - April --> June >- <br /> Quarter 3 - July --> September <br /> Quarter 4 - October --> December <br /> i <br /> Send to: SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. Hazelton, P. O. Box 2009 ' <br /> Stockton, CA 95201 466-6781 <br /> T 40 10/86 <br />