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f0�•'/yl (J <br /> INVENTORY RECONCILIATIOh— <br /> QUARTERLY SUMMARY REPORT FORM <br /> facility Name: (If � 51mc#l'-205— �l Ilam��� <br /> Tank / Size Product <br /> Facility Address: 33 <br /> DO <br /> "telephone : �� <br /> Person Filing / n <br /> Report ( �/ <br /> ElI hereby certify under penalty of perjury that all inventory variations for <br /> the above mentioned facility were within the allowable li /�mi <br /> Quarter. (No in Column i3 of the Inventory Reconciliation S M EIVE <br /> Inventory variations exceeded the allowable limits for thJAN 16 1992 <br /> hereby certify under persalt of 'L'fVWtFC K9 ENTAL HF4TH <br /> for <br /> was not due to an unauthorized (leak) release. (yesuinsorceColunm of the <br /> Ioven[ory Reconciliation Sheet) <br /> List date, tank /, and amount for all variations that exceeded the <br /> allowable limits. <br /> Date Tank <br /> Amount <br /> 2. <br /> -- <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 <br /> within 24 hours and an unauthorized release report sDubmittedEnvir�nmental Health <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 --> Jun <br /> Quarter 7 _ e <br /> July --) September <br /> atter - October --> December <br /> Send to: SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E . Hazelton , P .O . Box 2009 <br /> OCT 40 10/86 Stockton, CA 95201 466-6781 <br />