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INVENTORY RECONCILIATION <br /> QUARTERLY SUMMARY REPORT FORM <br /> t'aciLitr Name: .� �iT ,CZ6;'e,�� Tank i <br /> SizeProduct <br /> Fac i 1 i t Address: <br /> Te lephone :/� <br /> �C ff <br /> Person Filing ,� <br /> Report ��,C/7.-"�-!'� �� <br /> EJI 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 variation <br /> was not due to as unauthorized (leak) release. (Yes in Colum 13 of the <br /> Inventory Reconciliation Sheet) <br /> List date, tank 1, and amount for all variations that exceeded the <br /> allowable limits. <br /> Date Yank / Amount <br /> z. <br /> 3• .3 <br /> 4. - 1 <br /> s. _/ h <br /> 17 <br /> Addi ioaal dates/amouats shall be continued on a separate sheet of <br /> paper and attached_ <br /> if the source of the variation which. exceeded at-lowable limits was due to <br /> a leak the incident shall be retorted to $ ,J .L.H . D. Environmental licalth <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 /> ' ►ter. I �= January ->`March <br /> Q+-Aarter Z - April --? June <br /> Quarter 3 - Juty --) September <br /> Quarter 4 - October --) December <br /> Send to: SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HazelLo n. P .O . [Sox 2009 <br /> llCT 40 10/86 Stockton , CA 95201 466-6781 <br />