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INVENTORY RECONCILIATION <br /> QUARTERLY SUMMARY REPORT FORM <br /> IraciLity Name: Tank f Size. Product <br /> Facility,'Address; cr ' �1.sf�f 'c�.�✓_. �' 1 <br /> Telephone :/,1� / <br /> t Filing <br /> dL 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 /> E] Inventocy 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 an unauthorized (leak) rete se. (Yes in Column 13 of the <br /> Inventory Reconciliation Sheet) <br /> List date, tank f, and aaount for all variations that exceeded_,4c ` <br /> allowable lionits. � <br /> �S <br /> Date Tank f A=Kmat 1 ' <br /> 1 A <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 /> Lf 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 aca 1 th <br /> within 24 hours aad 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 /> Q+sarter _2 ---Ap.riL- - '-) June- <br /> "vQuarter 3 - July --? Scptcmhcr <br /> arter 4 October - cember <br /> Send to: SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E . gaze l Lott . P -0 . BOX 2009 <br /> Stockton . CA 95201 466-6761 <br /> LJGT 40 101 tib <br />