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INVENTORY RECONCILIATION <br /> QUARTERLY SUMMARY REPORT FORM <br /> Facility Hame: (? <br /> Tank Size. - Product <br /> Pacilit Address: '� i !>C1Ufrl ��'dvr <br /> Telephone <br /> Person Filing <br /> Report <br /> F] 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. ' Y <br /> hereby certify under penalty of perjury that the source for the varixtion <br /> was not due to an unauthorized (leak) releise. (Yes is Column 13 of the <br /> Inventory Reconciliation Sheet) <br /> List date, teak f, and amount for nil variations that exceeded the .` <br /> allowable limits. <br /> Date Tank Amount <br /> 1. d <br /> 2. <br /> 3. <br /> 4. <br /> 5. <br /> Additional dates/amounts shall he continued an x separate ■beet 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 health <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 I a ar �ri' <br /> ) <br /> }arter 2 - April Quarter I - July mber <br /> Quarter 4 - October --> December <br /> Send to: SAN JOAQUIN LOCAL HEALTH UIS'rHICT <br /> 1601 E. Hazc 1 t s�ii . P .O . Box 1009 <br /> Stockton , CA 95201 466-6781 <br /> UGT 40 10/ 86 <br />