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INVENTORY RECONCILIATION <br /> QUARTERLY SUMMARY REPORT FORM 0 <br /> Facility Dame: 2,5�� _e: <br /> Tank E Product, <br /> Pacilit �Jlddress: G/ � � < <br /> 7� <br /> Telephone :� p�l <br /> Person Filing <br /> RePorC <br /> QI hereby certify under penalty of perjury than all inventory variations for <br /> the above wenticned facility were within the allowable limits for this <br /> quarter. (Ho is Column B of the inventory Reconciliation Sheet) <br /> ElInventory variations exceeded the allowable limits for this quarter. ' I <br /> hereby certify Mader penalty of perjury that the source for the variation <br /> was not due to an unauthorized (leak) releise. (Yes in Column 13 of the <br /> Inventory Reconciliation Sheet) <br /> List date, tack f, and amount for all variations that exceeded the <br /> allowable listiits. <br /> Date Tank 0 Amount <br /> 4. <br /> Additional dates/amount: shall be continued on a separate sheet of <br /> paper and attached. <br /> If the source of the variation which. exceeded al-iowable limits was due to <br /> a leak the incident shall be reported to S .J .L.H.D. Environmental Health <br /> within 24 hours tad an unauthorised release report submitted. <br /> The quarterly summery report shall be submitted within 15 days of the end of each <br /> quarter. <br /> Quarter 1 j2auary March <br /> titter 2 - April --�Jun <br /> ,arter 3 - July he r <br /> Quarter 4 - October --> December <br /> Send to: SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E . Hazy l L oil , P -0 . BOX 2009 <br /> SLockton , CA 95201 466-6781 <br /> LIGT 40 10186 <br />