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Facility flame: /J/' <br />Facility Address: <br />Telephone: <br />Person Filing, <br />Report gam, <br />INVENTORY RECONCILIATION <br />QUARTERLY SUMMARY REPORT FORM <br />a <br />I hereby certify under Penaltyf <br />of that all inventory variations for <br />the above mentioned facility were within the allowable limits for this <br />quarter. (No in Columna 13of the loventory Reconciliation Sheet) <br />E] 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) release. (Yet in Column 13 of the <br />Inventory Reconciliation Sheet) <br />List date, tank 0, and amount for all variations that exceeded the <br />allowable liaits.. <br />Date Tank i Amount <br />2. <br />3. <br />4. <br />S. <br />lldditioaal dates/amouatt shall be continued oa 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 11calch <br />within 24 hours and an unauthorized release report submitted. <br />The quarterly summary report shall be Rubmitted within 15 days of the end of each <br />Quarter. <br />Quarter I - January <br />Q—rcer 2 - April --> Jure: <br />Quarter ) - Jul; --> Septcmh4'r <br />Quarter - october --> December <br />Send CO: SAN JOAQl1IN LOCAL HEALTH UISTH ICI' <br />1601 E. Ha7c1loll, I'.(). 11Ox ZOO') <br />40 1(l/KG Stockton, CA X15201 460-G7b1 <br />T' <br />