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0 <br /> INVENTORY RECONCILIATION <br /> QUARTERLY SUMMARY RF_PORT FORM <br /> Facility Name: I <br /> —�ana'-'5S Tank I Size Product <br /> Facility Address: l' 0, X ; 7� � ,.� ) <br /> '54- GG / <br /> u a r A,of <br /> Telephone : <br /> Fq_ � �U <br /> Person Filing <br /> Report JGrr,ass <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 /> ElInventory 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 Coles 13 of the <br /> Inventory Reconciliation Sheet) <br /> List date, tank #, and amount for all variations that exceeded the <br /> allowable limits. <br /> Date Tank F Amount ` <br /> 2. J48 <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 allowable limits was due to <br /> a leak the incident shall be reported to S .J . L . H . D . Environmental Hcalth <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 I - January March <br /> Quarter 2 - April --> June <br /> Quarter 3 - July --> September <br /> Quarter 4 - October --) December <br /> Send to: SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 I? . Hazelton , P . O . 13ox 2()09 <br /> UG"f 40 10/ 86 Stockton , CA 95201 466-6781 <br />