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� �' �' ' %", 1% <br />'s <br />INVENTORY RECONCILIATION <br />QUARTERLY SUMMARY REPORT FORM <br />is � yName: _ _ C L <br />ZAN <br />it / <br />r Address: �O t 11) 91)(gl� k <br />Telephone: `1 _qg, rl—,-;,-70 o <br />Person Filing �- <br />Report <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 />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) releise. (Yes in Column 13 of the <br />Inventory Reconciliation Sheet) _ <br />List date, tank f, and amount for all variations that exceeded th2. <br />allowable limits. <br />Date Yank P Amount <br />1. <br />2. <br />3. <br />r <br />4. <br />5. <br />Additional dates/amounts shall be contest""oo 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 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 1 - January --> March <br />Quarter 2 - April --> June <br />Quarter 3 - July September <br />ecce 4 - October -- 1k ccmbe <br />Send to: SAN JOAQUIN LOCAL HEALTH DISTRICT <br />1601 E. I:aze 1 t on , 11.0. Box 2009 <br />UCT 40 10/86 Stockton, CA 95201 466-67b1 <br />