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Y� <br /> INVENTORY RECONCILIATION <br /> QUARTERLY SUMMARY REPORT FORM <br /> Facility Names CO:,ni� ( ���'� qn ; Tank 1 Size. Product <br /> FacilityWdresst jot_ o <br /> Telephone : "?,h-Ul l <br /> Person Filing <br /> Report <br /> 1 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 que.TCr. IT <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 R Amount D <br /> 1. ' `' 'J <br /> 2. APR <br /> 3. <br /> 4 ENVIkUIVit!vIAL HLALTH <br /> 5. PERMIT/SERVICES <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. <br /> �j art -t - January --) March <br /> Quarter 2 - April --> June <br /> Quarter 3 - July --) September <br /> Quarter 4 - October --) December <br /> Send to: SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E . Hazelton , P . O . Rox 1009 <br /> Stockton , CA 95201 466-6781 <br /> UC 1' 40 101 6 <br />