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INVENTORY RECONCILIATION <br />QUARTERLY SUMMARY REPORT FORM19,4 X18 <br />Facility dame: cC <br />Facility Address:! <br />64 &,6d <br />Telephone: 6att <br />Person Filing <br />Report <br />Product <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 an unauthorised (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 # Amount <br />1. <br />2. <br />3. <br />4. <br />5. <br />Additioaat dates/amounts shall be continued on a separate sheet of <br />paper .end 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 Ilcalcl, <br />within 24 hours and an unauthorized release report submitted. <br />The Quarterly suarnary report shall be Fubmitted within 15 days of the end of each <br />Quarter. <br />Quar(cr 1 - January --) Harch <br />Q�arc4-r 1 - Apr 11 --> June <br />Quar(cr ) - July --) Jcp(ember <br />Q%Aarter 4 - October --) lk-ccmher <br />Send to: SAN JOAQU IN LOCAL HEALTH DISTRICT <br />1601 h:. Laze l t (in , P.O. Itinx 2009 <br />Stockton,CA X15201 4Gf�-67b1 <br />1' 40 10/80 <br />a <br />JAN 15 �� SH <br />� HSS <br />EN��R � Z 1S�Rv1C� <br />SER <br />