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INVENTORY RECONCILIATION <br /> QUARTERLY SUMMARY REPORT FORM <br /> Facility, Name: ty' 'tank # Size <br /> Product <br /> Pscitity Address: 550 N• <br /> Telephone : <br /> Person F��ctig <br /> Report Clyi GT KA <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 unauthorized (leak) releise. (Yes in Column 13 of the <br /> Inventory Reconciliation Sheet) _ <br /> List date, tank 1, and amount for all variations that exceeded the <br /> allowable lionits. <br /> Date Tank f Amount <br /> 2. :. <br /> 3. <br /> • s <br /> 4. <br /> ALTH <br /> S. <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 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 quarter! summary y re poet shall be Rubmitted within IS days of the end of each <br />�! quarter. <br /> -a Quarter 1 - January --) March <br />:3 Quarter 2 - April --1 June <br /> Quarter 3 - July --> Scptemhe!r <br /> Quarter 4 - October --> DLcember <br /> Send to: <br /> SAN JOAQU IN LOCAL HEALTIi DISTRICT <br /> 1601 E. !laze 1 L c»1 , 11 .0 . li()x 2009 <br /> Seockton , CA 95201 466-6761 <br /> LILT 40 10/86 <br />