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INVENTORY RECONCILIATION <br /> QUARTERLY SUMMARY REPORT FORM <br /> Facility Name: ZQh/� �hS rank IE <br /> (' Size Product <br /> Facility Address: t2s S' -/*-< S <br /> _p,o, ,u 9 7 <br /> Telephone : cc �y7,J atm <br /> Person Fi1in <br /> Report ma <br /> VMI 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 /> vas not due to an unauthorized (leak) release. (Yes in Column 13 of the <br /> Inventory Reconciliation Sheet) <br /> i <br /> List date, tank 1, and amount for all variations chat exceeded the <br /> allowable limits. <br /> Date Tank f Amount <br /> l_ <br /> 3. <br /> 2. <br /> ue <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-lowable limits was due 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 <br /> quarter. the end of each <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 E . Hazelecm , P . O . Box 2009 <br /> UCT 40 10/86 Stockton , CA 95201 466 -6781 <br />