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INVENTORY RECONCILIATION <br /> QUARTERLY SUMMARY REPORT I'ORM <br /> Facility Name: Tank <br /> Size Product <br /> Facility Address : j'j �- <br /> Telephone: , <br /> Person Filing <br /> Report: . r z , <br /> I hereby certify under penalty of perjury that -all inventory variations <br /> for the above mentioned facility were within the allowable limits for <br /> this quarter. (No in Column 13 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 varia- <br /> tion was not due to unauthorized ( leak) release. (Yes in Column 13 of <br /> the Inventory Reconciliation Sheet) . <br /> List date, tank It , and amount for all variations that exceeded <br /> the allowable limits . <br /> Date Tank # Amount <br /> 1 . <br /> 2 . <br /> 3 . <br /> 4 . <br /> 5 . <br /> Additional dates/amounts shall be continued on a separate sheet <br /> paper and attached. <br /> If the source of the variation which exceeded allowable limits was <br /> due to a leak, the incident shall be reported to San Joaquin Local <br /> Health District; Environmental Health Division, within twenty-four <br /> ( 24 ) hours and an unauthorized release report submitted. <br /> The quarterly summary report shall be submitted within fifteen (15 ) days <br /> of the end of each quarter. <br /> Quarter 1 - January---------->Marchr. IS <br /> Quarter 2 - April------------>June <br /> Quarter 3 ` July------------->September no- 7L /5 <br /> Quar-:er 4 - October---------->December15 <br /> Send to: SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 Ed <br /> . Hazelton, P.O. Box 2009 ,iit, <br /> Stockton, CA 95201 468-3420 <br /> _ y _ 1E, <br /> ENVIRONMENTAL HEA' <br /> EH 23 019 10/86 PER1A!T/SERVICES <br />