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INVENTORY RECONCILIATION <br /> QUARTERLY SUMMARY REPORT FORM <br /> Facility Name: Tank # Size Product <br /> T 00 <br /> Facility Address: 6, 7 e. 7 4 T- o <br /> Telephone : (Aoj) 9!lkox-j7 <br /> Person Filing <br /> Report 6Aa6 ; <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 in Columa 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 Yank # `Amount <br /> j. f6 T-1 7 _ �70g._1 <br /> 2. / i3 I-q 7--/ Z -3...0 <br /> 3. /0/2-0 rr�_ _^_ F-17 k ;3 • 7- <br /> 4. <br /> 4. T-17- -_S7, 9 <br /> 5. / T- Fri .7 <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 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 /> Quarter 1 - 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 E . Hazelton, P .O . Box 2009 <br /> Stockton , CA 95201 466-6781. <br /> UGT 40 10/ 86 <br />