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INVENTORY RECONCILIATION <br /> QUARTERLY SUMMARY REPORT FORM <br /> - <br /> Facility Name: Tank f Size Pr duct <br /> Facility,'Address: D� <br /> , . <br /> Telephone <br /> Person Filing ��s <br /> Report ��.�i _ <br /> 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) relelae. (Yes in Column 13 of the <br /> Inventory Reconciliation Sheet) <br /> List date, tank f, and amount for all variations that exceeded the <br /> allowable limits. <br /> Ails <br /> Date Tank f Awount {+� <br /> 4. <br /> 5. <br /> Additioaal 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 /> it leak the incident shall be reported to S ,J ,L.H.D. Environmental Hea l ch <br /> within 24 hours and ars unauthorized release report submitted. <br /> The quarterly summary report shall be submitted within 15 days of the end of each <br /> quarter. <br /> Quarter 1 - January -- March <br /> Quarter 2 —April June <br /> `Quarter ] - July --? Septcmhcr _ <br /> ;rtcr 4 October December <br /> Send to: SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. Haze 1 L gill , P .O . BOX 2009 <br /> SLockton , CA 95201 466 -6781 <br /> JGT 40 10/ 86 <br />