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INVENTORY RECONCILIATION <br />QUARTERLY SUMMARY REPORT FORM 0 1 <br />Facility Names <br />FAcility�Address: - <br />Telephone: - j <br />Person Fi ing <br />Report <br />�r <br />Tank # Mise' oh V'rFProduct <br />E� <br />Ga 0. <br />rJ'G'C? <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 />QInventory 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. (Yes in Column 13 of the <br />Inventory Reconciliation Sheet) <br />List date, tank f, and amount for all variations that exceeded the <br />allowable limits. <br />Date Tank f Amount <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 at-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 summary report shall be ,submitted within 15 days of the end of each <br />quarter. <br />Quarter 1 - January --> Harch <br />Quarter 3 - July --> Septembc^r <br />Quarter 4 - October --> N --comber <br />Send to: SAN JOAQUIN LOCAL HEALTH DISTRICT <br />1601 E. Haze I t on . P.O. Box 2009 <br />Stockton, CA 95201 466-6781 <br />LIGT 40 10/86 <br />