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INVENTORY RECONCILIATION <br /> QUARTERLY SUMMARY REPORT FORM <br /> Facility Naabe: 4y9f112 Tank <br /> Size Product <br /> Facility•Address: 7 SEG I tooc, <br /> Telephone : <br /> Person Filing <br /> Report <br /> 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 1]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 as unauthorised (leak) release. (Ye■ is Column 13 of the <br /> Inventory Reconciliation Sheet) <br /> List date, tack /, and aaounc for all variations that exceeded the <br /> allowable limits. <br /> Date Tank / Amount <br /> 1. <br /> 2. <br /> J. <br /> 4. <br /> 5. <br /> Additional dates/amounts shall be continued on a separate sheet of <br /> paper and accached. <br /> If the source of the variation which exceeded allowable limits was due to <br /> a leak the incident shall be reported to S .J . L . H . D. Environmental Health <br /> Wichin 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 /> ar ter - January --) March <br /> Quarter 2 - April --> Junc <br /> Quarter I - July --> September <br /> Quarter 4 - October --) Occcmber <br /> Send to: SAN JOAQUIN 1.0CA1, HEALTH DISTRICT <br /> 1601 E. Hazelton , P .O . liox 2()O7 k <br /> ;T 40 10/N(� Stockton , CA 75201 460-67bl <br /> ' <br />