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0 <br />INVENTORY RECONCILIATION <br />QUARTERLY SUMMARY REPORT FORM <br />Facility Name: <br />Facility Address: <br />Telephone: <br />Person Filing <br />Report .-may <br />APR 7 1989 <br />ENV PO V,,-NTALH�ALiN <br />PERMII /SERVICES <br />Tank I Size <br />Product <br />quarter. <br />'—'e -en <br />NLE.!°l1 <br />I - January --) <br />March <br />Quarter <br />2April-- <br />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 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 f Amount <br />2. <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 />Mithin 24 hours and an unauthorized release report submitted. <br />The quarterly summary report shall be <br />submitted within 15 days of the end of each <br />quarter. <br />/y/Quarter <br />I - January --) <br />March <br />Quarter <br />2April-- <br />Quarter <br />3 - July <br />September <br />Quarter <br />4 - October --> <br />December <br />Send to: <br />SAN JOAQUIN LOCAL HEALTH DISTRICT <br />1601 E. Hazelton, P.O. Box 2009 <br />Stockton, CA 95201 466-6781 <br />UGT 40 10/86 <br />