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INVENTORY RECONCILIATION <br /> QUARTERLY SUMMARY REPORT FORM <br /> Facility Name: zk(i IrSf�'ee 7 �33� <br /> Tank I Size P duct <br /> Facility Address: �C�� T ^ QU/C �� .' .� u <br /> Telephone : <br /> Person Fill'n y fin , <br /> R�?ort Com/ Ql S/Y(I <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 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 CO an unauthorized ( leak) release. (Yes in COlunm 13 of the <br /> Inventory Reconciliation Sheet) <br /> List date, tank 1, sad amount for all variat <br /> allowable limits. ions that exceeded the <br /> Date Tank / Amount <br /> 1 . <br /> 2 <br /> 3. <br /> 4. <br /> Additional daces/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 <br /> within 24 hours and an unauthorizedD. Environmental Health <br /> release report <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 E . Hazelton , P .O . Box 2009 <br /> UCT 40 10/86 Stockton , CA 95201 466-6781 <br />