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0 <br />INVENTORY RECONCILIATION <br />QUARTERLY SUMMARY REPORT FORM <br />Facility Name: <br />Facility 4ddress: & .:2 u <br />Telephone: <br />Person Filin <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 />ENVIROMENTAL HEALTH <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 A=unt <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 />Lf 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 I - January --> March <br />Qviarter 2 - April --> June <br />Quarter 3 - July --> Septemht!r <br />Quarter 4 - October.--> (kcember <br />Send to: SAN JOAQUIN LOCAL HEALI-H DISTRICT <br />1601 E. Hazelton. 1' .0 . Box 2009 <br />Stockton. CA 95201 466-6781 <br />UCT 40 10/86 <br />