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+� INVENTORY RECONCILIATION <br /> QUARTERLY SUMMARY REPORT FORM <br /> Facility Name: 'Tank i Size Product <br /> Facility�Addreaa <br /> Telephone : <br /> Person Filing <br /> Report <br /> I hereby certify under penalty of perjury that all inventory variations for <br /> the above vacationed facility were within the allowable limits for this <br /> quarter. (No in Coluam 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 is Column 13 of the <br /> Inventory Reconciliation Sheet) <br /> List date, tack #, and amount For all variations that exceeded the <br /> allowable limits. <br /> Date Tank 1 Amount <br /> 3. <br /> 4. <br /> Additional dates/amoucrs 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,p. Environmental health <br /> Within 24 hours and an unauthorized release report submitted. <br /> The quarterly summary report shall be Rubmitted within 15 days of the end of each <br /> quarter. <br /> Quarter 1 - January --) March <br /> ¢garter 2 - A " 1 --) June <br /> --Quarter ]f- Jul --> Scptemhcr <br /> arter 4 - October --? December <br /> Send to: SAN JOAQUIN LOCAL HEALTH UISTHICT <br /> 1601 E. Haze l C0n1 . P -0 - BOX 2009 <br /> Stockton , CA 95201 466-6781 <br /> UGT 40 10/ 86 <br />