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t I N� ififif <br /> INVENTORY RECONCILIATION s, <br /> QUARTERLY SUMMARY REPORT FORM tiILALT14 <br /> Facility <br /> ti��me: <br /> Tank f Size Product <br /> Facility','Address: IZ2' �e',�5�/��y✓= <br /> Telephone <br /> Person Filing _ <br /> Report <br /> E] 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 varistion <br /> was not due to an unauthorized (leak) release. (Yes in Column 13 of the <br /> Inventory Reconciliation Sheet) <br /> List date, tank f, and scoune for all variations that exceeded the <br /> allowable liatics. <br /> 7- <br /> Date Tank 0 Anumat <br /> /�- <br /> 2. 7 <br /> 3. - 7, 1 <br /> 4. <br /> Additioasl daces/amouats shall be contiaued 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.D. Environmenta L Uca l th <br /> WiChin 24 hours and an unauthorized release report submitted. <br /> The quarterly summary report shalt be submitted within 15 days of the end of each <br /> quarter. <br /> Quarter I - January March <br /> isr[�2 April - June <br /> Quarter 3 - July --> Sepcemher <br /> Quarter 4 - October --> December <br /> Send Co: SAN JOAQUIN LOCAL HEALTH UIS'rRICT <br /> 1601 E. bane I L0�i1 , 13 .0 . Box 2009 <br /> SLockCon . CA 95201 466-6781 <br /> LJGT 40 10/ 86 <br />