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INVENTORY RECONCILIATION <br />QUARTERLY SUMMARY REPORT FORM <br />�f��n n-,, <br />Facility dame: I��ALL.!" Tank I Size Product <br />Facility Address: <br />C. < <br />Telephone. <br />Person Filing- <br />Report r <br />I 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. (No in Column 13 of the Inventory Reconciliation Sheet) <br />laventory 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 as unauthorized (leak) release. (Yes in Column 13 of the <br />Inventory Reconciliation Sheet) <br />I <br />List date, tank f, and amount for all variations that exceeded the <br />allowable limits. <br />Date Tank I AinounC <br />1. <br />2. <br />3. <br />4. <br />5. <br />Additional dates/amounts 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 incidcnt shall be reported to S.J.L.H.D. Environmental Health <br />within 24 hours and an unauthorized release report submitted. <br />The quarterly summary report shall be submitted within 15 days of the end of each <br />quarter. <br />Quarter I - January --1 H.Irch <br />Q•Jarter 2 - April --> June <br />Quarter 3 - July --> >cptcmh.!r <br />Q,iarter 4 - October --> (?ec�mbcr <br />Send to: SAN JOAQU IN LOCAL HEALTH DISTRICT <br />1601 11. Ha•i.c• 1 t on , V.0. 11Ox ').009 <br />Stockton. CA 95201 460-6781 <br />i' 40 10/80 <br />