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WED <br /> INVENTORY RECONCILIATION <br /> OCT 1 0 1991 <br /> QUARTERLY SUMMARY REPORT FORM I ; ... : <br /> m F <br /> Facility. Nzn.,c: <br /> Tank t Sire. Product <br /> Ficilit <br /> Y llddress; `/ <br /> Telephone : <br /> Person Filing <br /> Report <br /> Xereby certify under Penalty of perjury that all inventory variations for <br /> the above mentioned FacilityX <br /> were within the allowable limits for this <br /> quarter. (No in Column 13 of the Inventory Reconciliation Sheet) <br /> lavcntory variations exceeded the all'ovable. limits for this quarter. I <br /> hereby certify under penalty of perjury that the source for the variation <br /> "As not due to an unauthorized (leak) relelge. (yes in COIL=n 13 of the <br /> raventory Reconciliation Sheet)' <br /> List date, tank 1, and amount for all variations that exceeded the <br /> allowable limits_ <br /> DateTank 0 Amount <br /> 1. <br /> 3. <br /> 4. <br /> 5. <br /> Additional datcs/amouncs chall be continued on a separate sheet of <br /> paper and attached. <br /> If the source .of Che variation which. exc'ccded al,-lovable limits was duct to <br /> A leak the incident shall. be rcporred toS .J L.H . D. Environmental 11caLth <br /> Within 24 hours and an unauthorized release report submitted. <br /> The quarterly summary report shall be Kubmicted vichin 15 days of the end of each <br /> quarter. <br /> Quarter I - Harch <br /> Q.i a Er t: 21, - April June <br /> arter <br /> July Suptcmbt-r <br /> (c"rtcr 4 October Dt.-cember <br /> Send to: SAN JOAQUIN LOCAL HEALTH DISTRIC-1- <br /> 1601 E . 1:17CIL4111 . P . O . 14c)-< 2()()g <br /> 140 10/86 -SLockr-on , CA 95201 466-6781 <br />