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S INVENTORY RECONCILlATIOft-/ <br /> �:ae m. <br /> NOV O 1441 QUARTERLY SUMMARY REPORT FORM <br /> 1�U5 Tank <br /> Facility Address: 6On) Size Product <br /> r�" <br /> Telephone : <br /> Person riling / <br /> ❑ I hereby certify under penalty of perjury that all inventory the above mentioned facility were within the allowable limsvforatioos for <br /> Quarter. (Ho in Column IJof the Loveotory Reconciliation Sheet) this <br /> loventory variations exceeded the allowable limits for this quarter. I <br /> hereby certify under penalty of perjury that the source for the variation <br /> vas nor due to an unauthorized (leak) release. <br /> Inventory Reconciliation Sheet) (Yes in Column 13 of the <br /> List date, tank /, and amount for all var <br /> allowable limits. iations that exceeded the <br /> D__te Tank / <br /> Amount <br /> 1. <br /> 2. -_ -- <br /> J. <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 <br /> within 24 hours and an unauthorized release u ittedonx Environmental Health <br /> e lease report submitted. <br /> The quarterly Summary report shall be submitted within 15 days of the end of each <br /> quarter. <br /> Quarter I - January --) March <br /> Qaarter 2 - April --> Jun <br /> Quarter ] _ e <br /> Quarter 4 - October __) September <br /> December <br /> Send to: SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E . Hazelton , P . O . Box 2009 <br /> OCT 40 LO/86 Stockton, CA 95201 466-6781 <br />