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9 <br />INVENTORY RECONCILIATION I <br />JUARTERLY SUMMARY REPORT FORI <br />Facility Nam: _ l / <br />Person Filing <br />Report <br />MENU tl� <br />-Product <br />-,/ <br />IDI 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 f, and amount for all variations that exceeded the <br />allowable Lioeits. <br />Date Tank f Amount <br />J <br />2. <br />3. <br />OF <br />5. <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 1 - January --J March <br />Quarter 2 - April --> June <br />Quarter 3 - July --> Septcmhi!r <br />Quarter 4 - October --> tkccmber <br />Send to: SAN JOAQUIN LOCAL HEALTH DISTRICT <br />1601 E. Hazelton. P.O. Box 2009 <br />Stockton, CA 95201 466-6761 <br />LJGT 40 10/86 <br />