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1% <br /> INVENTORY RECONCILIATION <br /> QUARTERLY SUMMARY REPORT FORM <br /> fM P <br /> Fat`ili' cF pE�SBRESHEARS CHEVRON #3-3823 Tank / Size Product <br /> litAddress. 824 EAST' VENLTE V <br /> Z o <br /> oda <br /> Telephone : <br /> Person Filing qr� <br /> Report (J2 Zj 2Z—j/ <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 Column 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 Column 13 of the <br /> Inventory Reconciliation Sheet) <br /> List date, tank i, and amount for all variations that exceeded the <br /> allowable limits. <br /> Date Tank R 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 whichexceeded 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 /> 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 . Hazelton , P .O . Rox 2009 <br /> Srockron , CA 95201 466-67bl <br /> UGT 40 10/86 <br />