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INVENTORY RECONCILIATION <br />U <br />AK( Q ARTERLY SUMMARY REPORT FORM <br />ENVIE lity Name <br />G p �S- <br />P41hLty Address: <br />t ` <br />Telephone: <br />Person Filing' <br />Report <br />0 <br />X <br />I hereby certify under penalty of perjury that all inventory the above mentioned facility were i <br />within the allowable limits <br />fo <br />Column 13 of the Inventor y variations for <br />quarter. (No to <br />y Reconciliation Sheet)r this <br />Inventory variatioos exceeded the allowable limits for <br />hereby certify under penalty of perjury <br />was not due this quarter. I <br />to an unauthorized y that the source for the variation <br />lnventory Reconciliation Sheet) releise. (yea in Column 13 of the <br />Liat date, tank / <br />allowable lio<ita., and amount for all variations that exceeded the <br />Date Tank f <br />— Amount <br />1. <br />3. <br />4. <br />Additional dates/amounts shall be continued <br />Paper and attached. on a separate sheet of <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. Enviro <br />Mithin 24 hours and an unauthorized r nmcntaL Health <br />etcase report submitted. <br />The quarterly summary report shall bie subm <br />7uarce r. tted within 15 days of the end of each <br />Quarter I - January --> March <br />Q�artcr 1 - ApriT— -_> June <br />Quarter 3 _ <br />Quarter 4 _ July --> Septcmher <br />October --> December <br />Send to: SAN JOAQUIN LOCAL HEALTH DISTRICT <br />1601 E. llazelLon, P.O. Box 2009 <br />11CT 40 10/86 <br />SLockton, CA 95201 466-6781 <br />