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INVENTORY RECONCILIATION <br /> QUARTERLY SUMMARY REPORT FORM <br /> Facility Name; / � �,/, 7 <br /> Tank f Size <br /> Product <br /> Facili .y•Address; _ilYr^ C� <br /> Telephone : �'•, ) ��,/i _ _- �� <br /> Person Filing <br /> Report — !iiir'/ �'� C�'_QJ <br /> Q L hereby certify under penalty of perjury that all inventory variations for <br /> the above mentioned facility were within the allowable Limits <br /> quarter. (No in Column 13 of the Loveatory Reconciliation for this <br /> Sheet) <br /> ❑ Inventory variation. exceeded the allowable limits for this quarter. Z <br /> hereby certify under penalty of perjury that the source for the variation <br /> was not due to so unauthorized (leak) release. (Yes'— <br /> in Columm IJ of the <br /> Inventory Reconciliation Sheet) <br /> List date, tank f, sad amount for all variations that exceeded the <br /> Allowable limits- <br /> Date Tank f Amount <br /> 1. <br /> 2. <br /> J. <br /> 4. <br /> 5. <br /> Additional dates/amouota 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 Ucalth <br /> within 24 hours and an unauthorized release report submitted. <br /> The summary report shall be submitted within 15 days of the end of each <br /> Quarter I - January --) March <br /> Quarter 2 - April --> June <br /> Quarter I - July --> Septemhcc <br /> Quarter 4 - October --) December <br /> Send to: SAN JOAQUIN LOCAL HEALTH UIS'1'HIC-1- <br /> 1601 E, l;azcllnn , P .O . ISclx )00') <br /> 1(;1' 40 to/HG <br /> Stockton . CA 95201 466-67b1 <br /> I <br />