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J <br /> LJ <br /> UJ <br /> INVENTORY RECONCILIATION <br /> QUARTERLY SUMMARY REPORT FORM 4 <br /> Facility Name: LC) 'Tank � ii`e Product <br /> Facility Address: /. j5 ,�, 7 t!- Grp <br /> ,[ 4 33 a a ca <br /> Telephone : 0 - <br /> Person Fili�}g <br /> Report J�rvc e,S <br /> OKI 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 /> was not due to an unauthorized (leak) release. (Yes in Column 13 of the <br /> Inventory Reconciliation Sheet) <br /> List date, tank #, and amount for all variations that exceeded the <br /> allowable limits. <br /> Date Tack 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 Health <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 /> Q+sarter 2 - April <br /> Quarter 3 - July --> September <br /> Quarter 4 - October --> l}ccember <br /> Send to: SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E . Laze 1 t_on , P . 0 . Box 2009 <br /> Stockton , CA 95201 466-6781 <br /> UGT 40 10f 86 <br />