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•INVENTORY RECONCILIATION <br /> QUARTERLY SUMMARY REPORT FORM <br /> Facility Name: Tank $ t Size Product <br /> Facility Address: L L rc p <br /> L 7 <br /> Telephone: 2.0 _ <br /> Person Filing � <br /> Report: . ((/0 0 <br /> • I hereby certify under penalty of perjury that all inventory variation: <br /> F] for the above mentioned facility were within the allowable limits for <br /> this quarter. ( No in Column 13 of the Inventory Reconciliation Sheet. . <br /> Inventory variations exceeded the allowable limits for this quarter. <br /> hereby certify under penalty of perjury that the source for the varia- <br /> tion was not due to unauthorized ( leak) release. (Yes in Column 13 of <br /> the Inventory Reconciliation Sheet) . <br /> List date, tank # , and amount for all variations that exceeded <br /> the allowable limits . <br /> Date Tank # Amount <br /> 2 . . <br /> APR 6 �e6 <br /> 3 . ENVIRONMENTAL <br /> 4 . PERMIT/SERVICES HEALTH <br /> 5. <br /> Additional dates/amounts shall be continued on a separate sheet <br /> paper and attached. <br /> If the source of the variation which exceeded allowable limits was <br /> due to a leak, the incident shall be reported to San Joaquin Local <br /> Health District; Environmental Health Division, within twenty-four <br /> ( 24 ) hours and an unauthorized release report submitted. <br /> The quarterly summary report shall be submitted within fifteen ( 15 ) days <br /> of the end of ea er. <br /> Quarter 1 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. Box 2009 <br /> Stockton, CA 95201 468-3420 <br /> Eff 23 019 10/86 <br />