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INVENTORY RECONCILIATION y <br /> QUARTERLY SUMMARY REPORT FORM <br /> Facility Name; i7G// +(� <br /> Tank I Size Product <br /> Facility-Address; <br /> TelephoneL�l <br /> Person FL ing <br /> Report /t/n`ae/ c�7eo9Z O./ <br /> 6 � � <br /> dI 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 Colu® 130f the Inventory Reconciliation Sheet) <br /> u inventory variations exceeded the allowable limits for this quarter. I <br /> hereby certify under penalty of perjury that the source for the variation <br /> was not due Co as unauthorized (leak) release. (Yes is Colusm IJ of the <br /> Inventory Reconciliation Sheer) <br /> List date, tauk /, and amount for all variations [hat exceeded the <br /> allowable limica_ <br /> Date Tank I Amount <br /> 1. <br /> Z. <br /> 3. <br /> 4. <br /> S. <br /> Additional dates/amouats shall be concioued on a separate sheet of <br /> Paper and attached. I - <br /> If the source of the w-riatian which. cxceeded allowable limits was due to <br /> a leak the incident shall be reporccd to S .J .L.H . D. Environmental health <br /> MtChtn 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 I - January __) March - --. <br /> Quarter 2 - April --) June <br /> Quarter l - July --) Scpccmha:r <br /> Quarter 4 - October --) December - _ <br /> Scnd to: SAN JOAQUIN LOCAL HEALTH UIS-1-HICT <br /> 1601 E. Ilazc 1 t , 1, .0 . Ito x 2009 <br /> 40 Ln/86 SLockton , t:A 95201 466-61b1 <br />