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! • a <br /> INVENTORY RECONCILIATIONUl� 2 � <br /> QUARTERLY SUMMARY REPORT FORM �NV1RO�1E`v"fA� HA�-TM <br /> R��t�rs��vtic�s <br /> Facility Name: r Tank I Size Product <br /> 1 <br /> Facility Address: - o <br /> Telephone : <br /> ZZL <br /> Person Filing <br /> Report <br /> I 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 quarter. I <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 1, and amount for all variations that exceeded the <br /> allowable limits. <br /> Date Tank I Amount <br /> 1. <br /> Z_ <br /> 3. <br /> 4. <br /> 5, <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 al-lovable limits was dose 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 /> i varier I - January --} March <br /> Quarter 2 - April -- une <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 466-6781 <br /> LICT 40 101$6 <br />