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INVENTORY RECONCILIATION 46 <br />QUARTERLY SUMMARY REPORT FORM <br />Facility Names ,j20\ <br />IPacility Wdress: 6(� <br />Telephone: 6 <br />Person Filing <br />Report au <br />y���lll�l <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 />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) s <br />:b <br />List date, tank d, and amount for all variations that ex lrc <br />allowable limits. <br />Date Tank f Amount` <br />ry-) <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-lowabte 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 I - January --J Harch <br />Quarter 2 - April --> June <br />Quarter 3 - July --> Septemhc:r <br />Quarter 4 - October --> Ik:cember <br />Send to: SAN JOAQU IN LOCAL HEALTH DISTRICT <br />1601 E. Hazelton. P.O. flax 2009 <br />Stockton, CA 95201 466-6761 <br />LICT 40 10/86 <br />