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INVENTORY RECONCILIATION <br />QUARTERLY SUMMARY REPORT FORM <br />F&CLUty. Name <br />. I .: - - j2. <br />T o /J <br />,meg -I <br />JAN 1 0 ""71 <br />NVIRONNIkENTAL HEALTH <br />L 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 />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 so unauthorised (leak) celeise. (Yes in Col 13 of the <br />Inventory Reconciliation Sheet) <br />List date, tank #, and amount for all variations that exceeded the <br />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 of <br />paper 2nd attached. <br />If the source of the variation which. exceeded ai•lowable limits was due to <br />a leak the incident shall be reported to S,J.L.H.D. Environmental Health <br />within 24 hours and an unauthorized release report submitted. <br />The quarterly suaimary report shall be submitted within 15 days of the end of each <br />quarter. <br />Quarter 1 - January --> March <br />Quarter 2 - April --> June <br />Quarter 3 - July --> September <br />Quarter 4 - October --? tkkcember <br />Send to: SAN JOAQUIN LOCAL HEALTH DISTRICT <br />1601 E. Hazelton, P.O. Box 2009 <br />Stockton, CA 95201 466-67&1 <br />ICT 40 10/86 <br />