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• <br /> INVENTORY RECONCILIATION <br /> QUARTERLY SUMMARY REPORT FORM <br /> Facility Name: /�f /�Ja �Jc✓ �hh �� Yank i Size Product <br /> Facility Address: MAIAJ S i 5 ✓ rr` e. I <br /> z`SOc-� e� /ead <br /> Telephone : �5"' 5-0(e <br /> Person Filingy�� <br /> Report <br /> ElI 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 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 1, and amount for all variations that exceeded the <br /> allowable limits. <br /> Date Tani, t :.mouat <br /> 1. <br /> 2. <br /> 3. <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 /> a leak the incident shall be reported to S .J .L .H . D . Environmental Hcalth <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 cacti <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 DISRICT <br /> 1601 E . Hazelton , P . O . IiOx 2009 <br /> Stockton , CA 95201 466-67b1 <br /> UGT 40 10/ 86 <br />