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INVENTORY RECONCILIATION <br /> QUARTERLY SUMMARY REPORT FORM <br /> F.cilicT Name: <br /> Tank f Size <br /> Product <br /> Pacility address: <br /> Telephone : <br /> Person Filin <br /> Report <br /> L hereby certify under pcoa[t of <br /> the above T perjury that all inventory variations for <br /> ®encioned faci.litT were within the allowable limits for this <br /> quarter. (No in Colum" 130f the Lnveatory Reconciliation Sheet) <br /> El <br /> Iaventocy variations exceeded the allowable limits t for this quarter. y <br /> hereby rectify under <br /> Penalty of perjury that the source for the variation <br /> '46 not due to an unauthorized (Leak) release. (Yes in Colu=n 13 of the <br /> Inventory Reconciliation Sheet) <br /> Last date, tack 1, and amount for all variations that exceeded the <br /> Allo-able li,,its. <br /> Date Tank I <br /> Amount <br /> D <br /> Nt <br /> 2. V L <br /> JAN 2 3 1990 <br /> 4. NVIRONMENTAL HEALTH <br /> s. PERMIT/SERVICES <br /> additional dates/amouocs chill be continued on a separate sheet of <br /> Paper 2nd accached. <br /> Lf the source of the variation which <br /> a leak the Icccccdcd allowable limits was due to <br /> incident shall be reported to $ ,J .L. H . D. Environmental llcalch <br /> Within 24 hours and an unauthorized release report submitted. <br /> The quarterly suaccary report shall be �cubmittcd <br /> quarter, within IS days of the end of each <br /> Q�»rC,�r I - Jsnuwry --) Ma«►e <br /> Qu a r t,.r 3 - J,a l --) $ <br /> y e('CCmt,e�r <br /> Q1a4rcer 4 - October --> <br /> k cc-mbc r <br /> Send to: SAN .JOAQUIN LOCAL HEALTH UIS'1'R1C•1' <br /> 1601 E . I:.IrcItnn , 1' .O . <br /> �,U 1 �/H t, :�tockton . CA 95201 1460 -67b ]T' . <br />