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INVENTORY RECONCILIATION <br /> QUARTE LY SUMMARY REPORT FORM <br /> Facility Name : - <br /> _ Tank # Size Product <br /> Facility Address : 5 3 - t rU <br /> �Il;4:m t7« T -- <br /> Telephone : `LO92.3 <br /> Person Fili g _ <br /> Report : Rest - - k'n/'A PP <br /> [ ] I Hereby certify under penalty of perjury that all inventory <br /> variations for the above mentioned facility were within the allowable <br /> limits for this quarter. (No in Column 13 of the Inventory <br /> Reconciliation Sheet ) . <br /> ] Inventory variations exceeded the allowable limits for this quarter. <br /> I hereby certify under penalty of perjury that the source for the <br /> variation was not due to an unauthorized (leak) release . (Yes in <br /> Column 13 of the Inventory Reconciliation Sheet) . <br /> List date, tank # , and amount for all variations th4f� e xceeded the <br /> allowable limits . <br /> f� <br /> Date Tank # Amount <br /> 1 <br /> 2 . <br /> 3 . <br /> 4 . U <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 <br /> to a leak the incident shall be reported to S.J.L.H.D. Environmental <br /> Health within 24 -hours and an unauthorized release report submitted . <br /> The quarterly summary report shall be submitted within 15 days of the <br /> end of each quarter. <br /> Quarter 1 - 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 /> Stockton, CA 95201 466-6781 <br /> T 40 10/86 <br />