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ONVENTORY RECONCILIATION <br /> QUARTERLY SUMMARY REPORT FORM <br /> Facility "a ,f k/1& S()K)E�Tr tx�l��1PT, �{ Tank f Size Product <br /> w <br /> Facility Address& i_-{ on <br /> [IRrJf EC_0 , <br /> Telephone: <br /> Person, ling�� �n <br /> Reports �ti Q <br /> I hereby certify under penalty of perjury that all inventory variations for <br /> the above mentioned facility were vi-,Ain the allowable limits for this <br /> quarter. (No in Column 13 of the Iovcotory Reconciliation Sheet) <br /> Inventory variations exceeded the allowable'limits for tbii qua'fG"rr is <br /> beteby certify under penalty of perjury that the source for,,the vara a <br /> was not due to an unauthorised (leak) release. (YesT in Coliab%I of t <br /> mob � <br /> Inventory nacoiliation "Got)) <br /> e <br /> ' List date, teak to and amount for all variations *dad the <br /> � ,SF��CFeA <br /> allowable limits. <br /> Ne <br /> Date Tank i Fount <br /> 2. <br /> 3. <br /> 4. _7"� <br /> Additional dates/amucts 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 unauthorised release report submitted. <br /> The quarterly summary report shall be submitted within IS days of the end of each <br /> quarter. <br /> Quarter 1 - January --> March <br /> Quarter 2 - April June <br /> Quarter 7 - July --> September <br /> Quarter 4 - October --> December <br /> Send to: SAN JOAQUIN LOCAL. HEALTH DISTR�CT <br /> 1601 E. 1(eze1ton ,-P •0 . Box 2009 <br /> Stockton , CA 95201 466-6781 <br /> UGT 40 10/86 <br />