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INVENTORY RECONCILIATION : <br /> QUARTERLY SUMMARY REPORT FORM TY <br /> Facility lfamat hatl> ��A4s�cJYN.c./ Tank Sire <br /> Product <br /> iacilit AAdcoast !2 � <br /> Telephone: 00 <br /> Person Filing <br /> Report �� <br /> U ` bereby certify under penalty of perjury that all inventoryvariations o <br /> the above mentioned facility were within the allowable lims for this f r <br /> quarter. (No in Column 13 of the inventory Reconciliation Sheet) <br /> ❑ Iaveatory variations exceeded the allowable Limits for this quarter. I <br /> bereby esrtify under penalty of perjury that the source for the variation <br /> was not due to an unauthorized (leak) releist. (yes in Colum 13 of the <br /> Inventory Reconciliation Sheet) <br /> List date, tack ft and amount for all variations that exceeded the <br /> allowable limits. <br /> Date Tank / Amount <br /> 1. <br /> 2. <br /> 3. <br /> 4. <br /> S. <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 /> leak the incident shall be reported toEnvironmental Ucalth <br /> within 24 hours and an unauthorised release report submitted. <br /> The quarterly summary report shall be submitted within 15 days of the end of each <br /> quarter. <br /> Quarter I - January --> March <br /> Quarter 2 - April --> June <br /> arter July --> September ' <br /> arter 4 - October .-> December <br /> Send to: SAN JOAQUIN LOCAL HEALTH UIS'1'NIC'1' <br /> 1601 E. Itazeltnn , P .O . Box 2007 <br /> QCT 40 lO/KG SLockton , CA 95201 466-6761 <br />