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t <br /> INVENTORY RECONCILIATION <br /> QUARTERLY SUMMARY REPORT FORM <br /> Facility Name: Tank -EL-Zt Product <br /> L% !� <br /> FacilityAddress: ��G/ Gu'� / � fr✓Gr�!_ �. � .� <br /> Te le phone <br /> Person Fiiin <br /> Report <br /> g<-hereby certify under penalty of perjury that all inventory variations for <br /> the above onencioned 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. ' Y <br /> hereby certify under penalty of perjury that the source for the variation <br /> was not due to as unauthorized (leak) ireleise. (Yes is Column 13 of the <br /> Inventory Reconciliation Sheet) <br /> List dace, tank #, and amount for all variations that exceeded the <br /> allowabLe licnits. <br /> Date Tank 0 Amount <br /> 1. <br /> 2. <br /> 3. <br /> 4. <br /> 5. <br /> Additional datesjamouncs shall be continued on a separate sheet of <br /> paper and attached. <br /> rf 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 Ucalth <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 ! - January --? March ��� <br /> Qu4rter 2 - April --} June <br /> Quarter 3 - July --> septcmbe r <br /> Quarter 4 - October --} 6cce61989 <br /> JAN <br /> send to: SAN JOAQUIN LOCAL HEALTH DISTRICT EiVVRONIaMENTAL HEALTH <br /> 160L E. Hazelton . P .O . [lox 2009 PERMIT/SERVICES <br /> Stockton , CA 95201 466-6781 <br /> JGT 40 10/ 86 <br />