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INYENTORY RECONCILIATION <br /> QUARTERLY SUMMARY REPORT FORM <br /> Facility aIDe:N �20 <br /> Tank t Size <br /> Facility•Addresa: Product <br /> Telephone : <br /> Person Filing S r <br /> Report <br /> L hereby certify under penalty of perjury that all inventory variations for <br /> the above mentioned facility were within the allowable limit■ for this <br /> quarter. (No in Column 13of the Lnventory Reconciliation Sheet) <br /> ❑ Inventory variations exceeded the a <br /> hereby certify under llowable limits for this quarter. I <br /> penalty of perjury that the source for the variation <br /> was not due to An unauthorized (leak) releisc. (Yes in Column i] of the <br /> Inventory Reconciliation Sheec) <br /> Last date, tank /, and amount for all variations <br /> allowable limits. Chat exceeded the <br /> Date Tank I Amount <br /> 1. <br /> 4. <br /> 5. <br /> A.iditional daces/amounts shall be continued on a separate sheet of <br /> Paper and attached. <br /> If the source of the variation whichexceeded allowable limits vas due to <br /> a leak the incident shall be reported to S .J . L. H . D . <br /> Envir <br /> Within Z4 hours and an unauthorized release report submictedo ntal Iical[h <br /> quarter.e uarterly summary report shall be eubmitced within 15 days of the end of each <br /> Quarter I - January --) Harch <br /> gAartcr Z - April --) June <br /> Quarter 7 - July --> Sepccmh.:r <br /> Quarter 4 - October --) December <br /> Send to: SAN JOAQUIN LOCAL HEALTE UIS'I'KICT <br /> 1601 E . 1l.,rclt (ul . 1' . 0 . Box 2g07 <br /> Stockton , CA 95201 466 -6761 <br /> iG1' 40 l0/86 <br />