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INVENTORY RECONCILIATION <br /> QUARTERLY SUMMARY REPORT FORM <br /> Facility Name: /-6/ Tank i Size ropuct <br /> Q <br /> Facility Address: U <br /> _ � - 0 <br /> Telephone : <br /> ReporPerson <br /> ❑ 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 is Column 13 of the inventory Reconciliation Sheet) <br /> R <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) releiee. (Yes in Column 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 Tank P Amount <br /> 1. e <br /> x. <br /> JAN 1 6 1900 <br /> ENVIRONMENTAL I-JE. <br /> 3' <br /> PERM IT/SER'VICES <br /> 4. <br /> S. <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 /> • leak the incident shall be reported to S •J ,L.H.D. Environmental llcalch <br /> :ithin 24 hours and an unauthorised release report submitted. <br /> The Quarterly summary report shall be submitted within 15 days of the end of each <br /> Quarter. <br /> Qu"rter 1 — January <br /> Quarter 2 - ApriL --) June <br /> Quarter 3 - July --> September <br /> Quarter 4 - October --> December <br /> Send co: SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HazeIlom , P .O . BOX 2O" <br /> SLackCon , CA 95201 466-67bl <br /> lu;T 1.0 10/80 <br />