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INVENTORY RECONCILIATION <br />QUARTERLY SUMMARY REPORT FORM <br />FacLUtr Names �Z X/1? A,l <br />Facility Address / X71 All Mrvy �g <br />Telephone: <br />Person Filing <br />Report�ti,,;�� <br />Tank # Size Product <br />12 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 />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 unauthorised (leak) releise. (Yes in Column 13 of the <br />Inventory Reconciliation Sheet) <br />List date, tank #, and amount for all variations that exceeded t <br />allowable limits. <br />Date Tank # Amount �, V <br />1. �;� <br />2.F1 <br />101 ;'� E5 <br />3. , v��CNM- E-\' <br />�'t � M <br />4. <br />S. <br />Additional dates/amounts shall be contioued on a separate sheet of <br />paper and attached. <br />If the source of the variation which.erceeded allowable limits was due to <br />it 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 1 - April --) June <br />Quarter l - July --) Septemh(!r <br />Quarter 4 - October --> Dc -comber <br />Send to: SAN JOAQUIN LOCAL HEALTH DISTRICT <br />1601 L. liaze l t o+n , P.O. Box 2009 <br />Stockton, CA 95201 466-6781 <br />T 40 10/86 <br />