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v <br /> INVENTORY RECONCILIATION <br /> QUARTERLY SUMMARY REPORT FORM <br /> Facility Name; /�, - <br /> =L= �` — �_ Tank f Size <br /> i r Product <br /> Facility Address: <br /> Telephone : <br /> Person Filing <br /> Report <br /> QI 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. (Ho in Column 13 of the loveatory 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 Column 13 of the <br /> Inventory Reconciliation Sheet) —' <br /> List date, tank f, and amount for all variations that exceeded the <br /> allowable limits. <br /> Date Tank f Amount <br /> 3. <br /> 4. <br /> 5. <br /> Additional dates/amounts shall be contioued on a separate sheet of <br /> Paper and attached. <br /> If the source of the variation which. exceeded allowable limits vas due to <br /> a leak the incident shall be reported to S ,J ,L. H . D. <br /> Within 24 hours and an unauthorized release report sub ittedonmcntal Ucalth <br /> The Quarterly summary report shall be Rubmitted within IS days of the and of each <br /> quarter. <br /> Quarter 1 - January --) Harch <br /> Quarter 2 - April --) June <br /> Quarter 3 - July --) Septcmhcr <br /> Quarter 4 - October --) (kcember <br /> Send to: SAN JOAQUIN LOCAL HEALTH UIS'1'RIC1' <br /> 1601 E. I:azc1t4m , P .O . liox 2009 <br />;a' 40 10/86 Stockton . CA 95101 466 -67b1 I <br />