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INYENTORY RECONCILIATION <br /> QUARTERLY SUMMARY REPORT FORM <br /> Facility Name; .� 7 <br /> / Tank I Size <br /> Pacility<Addreaa: Product <br /> / OAS iese <br /> Telephone : _ G� <br /> Z dire <br /> Person Filing�� , <br /> Report <br /> r--�� / CYb o,• <br /> LI 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. (Mo in Column IJ of the inventory Reconciliation Sheet) <br /> ❑ 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 to an unauthorized (leak) releise. (Yes in Colu= IJ of the <br /> Inventory Reconciliation Sheet) <br /> List date, tank /, and amount for all variations that exceeded the <br /> allovable limits_ <br /> Date Tank I Amount <br /> 1. <br /> ��- <br /> 3. <br /> 4. <br /> Additional daces/amouats 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 Hcalth <br /> within 24 hours and an unauthorized release report submitted. <br /> The quarterly su— ry report shall be submitted within <br /> quarter. I$ days of the end of each <br /> Quarter I - January --) March - <br /> Quarccr 1 - April --> June <br /> Quarter 3 - July --) September <br /> Quarter 4 - October --) <br /> December <br /> Send to: SAN JOAQUIN LOCAL HEAL11i DIS'1'RlC'I' <br /> 1601 E. I:azcllnn , 1, .0 . 8()x 2009 <br /> 40 l0/HG Stockton . CA 95201 466-67bl <br />:1' <br />