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INVENTORY RECONCILIATION <br />QUARTERLY SUMMARY REPORT FORM <br />FaciLity dame: <br />F:cility Address: �,/;�' Al <br />Telephone: C/ /6 g <br />Person Film A/Report �a�, <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. (Ko in Column 13 of the Inventory Reconciliation Sheet) <br />E] 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 as unauthorized (leak) releise. (Yes in Column 13 of the <br />Inventory Reconciliation Sheet) <br />List date, tank I, and amount for all variations that exceeded the <br />allowable lionits. <br />Date Tank f Amount <br />1. <br />2. <br />3. <br />4. <br />5. <br />Additional dates/amounts shall be continued on a separate sheet of <br />paper 2nd attached. <br />If the source of the variation which. exceeded al-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 I - January --) March <br />Q,1artec 2 - April --> June <br />Quarter 3 - July --> Scptcmhc.c <br />Quarter 4 - October --) (kcember p <br />Send to: SAN JOn UIN LOCAL HEALTH DISTRICT <br />1601 L. !laze 1 t on , P.O. . Box 2009 MAR 193 <br />Stockton, CA 95201 466-6781 <br />Uc;z' 4U 10/ iiG ENVIROMENTAL HEALTH <br />FERMIT/SERVICES <br />� <br />