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INVENTORY RECONCILIATION <br /> QUARTERLY SUMMARY REPORT FORM� ,ny <br /> Facility Name' Tank Size Product <br /> ,P,v. 6, c7 <br /> Facility Address: = 0C C- c <br /> L .3 U C J 'ad,--'f fQ <br /> Telephone : 7T <br /> Person FiliIlk <br /> Report <br /> C9I 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 /> QInventory 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 Colum 13 of the <br /> Inventory Reconciliation Sheet) <br /> List date, tank #, and amount for 211 variations that exceeded the <br /> allowable limits. <br /> Date 'Tank I Amount <br /> 1_ <br /> z. <br /> 3. <br /> 4. <br /> S. <br /> Additional dates/amounts shall be continued on a separate sheet of <br /> raper 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 Health <br /> within 24 hours and an unauthorized release report submitted. <br /> The quarterly sua=ary report shall be submitted within 15 days of the end of each <br /> quarter. <br /> Quarter I - January --) March <br /> Quarter 2 - April --> -lune <br /> Quarter 3 - July --) September <br /> Quarter 4 - October --) December <br /> Send to: SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E . Haze l t-o" , P . 0 . Box 2()()9 <br /> Stockton , CA 95201 466-6781 <br /> UGT 40 10186 <br />