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INVENTORY RECONCILIATION LJ <br /> QUARTERLY SUMMARY REPORT FORM k [(// <br /> Facility Name: �. j'q- - .��„i - �{ Tan a ize Product <br /> k- <br /> Facility Address: <br /> Telephone : 7 q -r2 / I <br /> Person 1i, ng <br /> Report J �1,1,— <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 13of the Inventory Reconciliation Sheet) <br /> Inventory variations exceeded the allowablelimits 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 #, and amount for all variations that exceeded the - <br /> allowable limits. <br /> Date Tank # Amount <br /> 3- <br /> 4. <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 Health <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 each <br /> quarter. - <br /> Quarter 1 - January --) March <br /> Quarter 2 - April --) June <br /> Quarter 3 - July --) Septemhcr <br /> Quarter 4 - October --) December <br /> Send to: SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E . Hazelton , P . O . Box 2009 <br /> Stockton , CA 95201. 466-6781 <br /> UGT 40 10/86 <br />