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i s . <br /> INVENTORY RECONCILIATION <br /> QUARTERLY SUMMARY REPORT FORM <br /> Facility Name: Tank # Size Produc <br /> oS� C : <br /> L4000 <br /> Facility Address: <br /> Telephone : <br /> Person Filing <br /> Report <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 Colum= 13 of the Inventory Reconciliation Sheet) <br /> Inventory 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 Colu= 13 of the <br /> Inventory Reconciliation Sheet) <br /> List date, tank #, and amount for all variations ;a <br /> ' allowable limits. <br /> Date Tank f Amount <br /> 2. <br /> 3_ <br /> 4_ <br /> 5. <br /> Additional dateslamounts shall be continued on a separate sheet of <br /> Qpaper and attached. <br /> If the source of the variation which exceeded allowable limits .was due to <br /> f s 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 <br /> aartcr Z - April --> June <br /> Quarter 3 - July --> ;eptember <br /> cart,, 4 - October =-> December <br /> Send to: SAN JOAQUIN LOCAL HEALTh DISTRICT <br /> 1 601 4ti0 , <br /> `Lockton • CA 95201 466 - 6781 <br /> tl :T 40 10/ 86 <br />