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INVENTORY RECONCILIATION <br /> QUARTERLY SUMMARY REPORT FORM <br /> Facility. Name; 'Tank I Size Product <br /> Pacility Address: <br /> L <br /> Telephone : - Z.-Z <br /> Person IOf l <br /> Report a � kft L-� <br /> J�Q L hereby certify under penalty of perjury that all inventoryvariations <br /> the above mentioned facility were within the allowable Lims for this <br /> for <br /> quarter. (No in column 13 of the Inventory Reconciliation Sheet) <br />. i <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 /> vas not due to an unauthorized (leak) releise. (Yes in Column 13 of the <br /> Lnventory Reconciliation Sheet) <br /> List date, tank 1, and amount for all variations that exceeded the <br /> allowable limits. <br /> Date Tank f Amount <br /> 1. <br /> 2. <br /> 3. <br /> 4. <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 quarterly summary report shall be submitted within 15 days of the end of each <br /> quarter. <br /> Quarter I - January --) March <br /> Quarter 2 - April --> June <br /> i Quarter 3 - July --> Scptemht!c <br /> Quarter 4 - October --> 'cember <br /> Send to: SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 160L E. Hazelton . 11 .0 . 11Ox 2009 <br /> Stockton , CA 95201 466-6761 <br /> Ur,T 40 10/86 <br />