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40 <br /> INVENTORY RECONCILIATION <br /> QUARTERLY SUMMARY REPORT FORM <br /> Facility Name: Tank # Size Product <br /> G10 <br /> Facility Address: � d %� rc <br /> cc r t cc <br /> Telephone : �Y tl7a <br /> Person Filing / ! <br /> Report ,e rr, 5 /77 Cc�4JeI� <br /> IXI 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. Colum 13 of the Inventory Reconciliation Sheet) <br /> QInventory 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 /> J <br /> List date, tank 1, and amount for all variations that exceeded the <br /> allowable limits. <br /> Date Tank f Amount <br /> 1. <br /> 2. <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 flea Lth <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 --? t}�cember <br /> Send to: SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E . haze l t-ml , P .O . BOx 1()()9 <br /> SLockton , CA 95201 466-6788 <br /> UGT 40 10/86 <br />