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INVENTORY RECONCILIATION <br /> QUARTERLY SUMMARY REPORT FORM <br /> Facility Haase: <br /> Tank Ik Site <br /> product <br /> Q. Q'R - <br /> Telephone : Z) <br /> Person Filing -0 <br /> Report M1 C <br /> ------------------------- <br /> 1 hereby certify under penalt of <br /> the above y perjury that all inventory variations for <br /> mentioned facility were within the allowable limits for this <br /> quarter. (No in Columna 13ef -,ht Taventary Rcconciiiation Sheet) <br /> Inventory variations exceeded the allowable Limits for this quarter. Y <br /> hereby certify under penalty of perjury that the source For the variation <br /> was not due to aA unauthorized (leak) releise. (Yes in Colin 13 of the <br /> Inventory Reconciliation Sheet) `- <br /> List date, tank I, and amount for' ali variations that exceeded the <br /> allowable limits_ �E <br /> [)ate Zu <br /> Wank I Amount . <br /> 3. <br /> 4. t`Q. pA\` <br /> 5. <br /> Additional dates/amounts shall be continued on a separate ■heet of <br /> Paper and attached. <br /> If the source .of the variation which- exceeded al-lovable limits was dun Co <br /> leek the incident ahal1, be reported to S .J . L. H . D . Envi ronmcnCs l Elca l th <br /> Within 24 hours and an unauthorized release report submitted. <br /> 'Chc quarterly summary report shall be submitted within <br /> quarter. IS days of the end of each <br /> Quarter 1 - January --) March <br /> uarcer Z - April _-> June <br /> arrer 3 July -_> Septemher <br /> (~jartcr 4 - Octobcr - -) <br /> E-eccmbcr <br /> Send to: SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601. I: . Ii,a�c l taut , 1' .0 . [Sox 2009 <br /> 40 10/86iockton , CA 95201 466 -67€x1 <br /> �° <br />