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INVENTORY RECONCILIATION <br /> QUARTERLY SUMMARY REPORT FORM <br /> Facility Name: Tank f Site. Product <br /> 4e ITelephone <br /> Person Filing <br /> Report <br /> 0 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 CoLumq B 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 an unauthorized (Leak) release. (Yes in Column 11 of the <br /> Inventory Reconciliation Sheet) <br /> List date, tank f, and amount for all variations that exceeded the { <br /> allowable limits. <br /> Date Yank f Amount <br /> 1. r <br /> 2. <br /> 3- c �L - <br /> 4. <br /> 5. <br /> Additional dates/amounts shall be continued on a separate sheet of <br /> paper and attached. <br /> if the source of the variation which. exceeded al-lowabLe limits was due to <br /> a lesk 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 aubmitted within 15 days of the end of each <br /> quarter. <br /> Quarter 1 - January --> March <br /> Q+iarcer 2 - April June <br /> a rt July --> Scntcmhcr , <br /> Quarter 4 October --) Occember <br /> Send to: SAN JOAQLlIN LOCAL H)rAL1'li L)I5'1'lt1CT <br /> JAN 1 '5: 67 <br /> 1601 E . haze l t oil . P .O . Box 2009 ENVIRO-MENTAL HEALTH <br /> SLockton . CA 95201 466-6761 EERMIT/SERVICES <br /> LILT 40 10/86 <br />