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INVENTORY RECONCILIATION <br /> QUARTERLY SUMMARY REPORT FORK <br /> • Facility MameTpy �U�1 LG <br /> Tank / Site Product <br /> Facility Address: f <br /> Telephone : <br /> Person Filing <br /> Report 5� tiirFQ �cno_ <br /> iWL hereby certify under penalty of perjury that all inventory variations for <br /> the above oeationed facility were within the allowable limits for this <br /> Quarter. (Ho in Column 13of 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 13 of the <br /> Inventory Reconciliation Sheet) <br /> List date. tank /, and amount for all variations that exceeded the <br /> allowable limits. <br /> Date Tank I Amount <br /> 3. <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 allowable limits was due to <br /> a leak the incident shall be reported to S .J .L.H. D. Environmental Health <br /> within 14 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 - January --) March <br /> Quarter 2 - April --) June <br /> Quarter 3 - July --) September <br /> Quarter 4 - October --) December <br /> Send to: SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> • 1601 F . Hazeltinl . P .O . Rom 2009 <br /> ;T 40 10/ 86 Stockton . CA 95201 466 -6781 <br />