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INVENTORY RECONCILIATION <br /> QUARTERLY SUMMARY REPORT FORM <br /> Facility Name: + _ Tank i Size <br /> / Product <br /> Facility Address: <br /> 560 <br /> Telephone : y� ,>,_. C y / <br /> Person Filing <br /> Report �7c �J7t� o Y�, <br /> L�j 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 Colum<+ I1 of the <br /> Inventory Reconciliation Sheet) <br /> List date. tank f, and amount for all variations that exceeded the <br /> allowable limits. <br /> Date Tank / Amount <br /> 2- � �' � ! <br /> 3. Q n <br /> 4. <br /> 5, ENVIRON ENTAL HEALTH <br /> F EWIIT/SERVICES <br /> Additional dates/amounts shall be continued on a separate sheet of <br /> paper and attached. <br /> If the source of the variation whichexceeded allowable Limits was due to <br /> A leak the incident shall be reported to S .J . L. H . D. Environmental lfcalth <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 /> Quarter 1 - January --) March <br /> Qiarter 1 - April --) June <br /> Quarter ) - July --) Septemher <br /> Quarter 4 - October --) (kcember <br /> Send to: SAN JOAQUIN LOCAL HEAL7'li UISTIUCT <br /> 1601 E . I!azcll „n , P . O . Hox 2()09 <br /> CT 40 10/ 86 Stockton , CA 95201 466-67b1 <br />