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INVENTORY RECONCILIATION <br />QUARTERLY SUMMARY RF_PORT FORM <br />Facility Name; f'1ir �•a � �• � <br />c � <br />Facility Address; <br />9's - <br />Telephone: <br />Person Fi �ing 7 i_s <br />Report <br />1 hereby <br />ertif <br />the above cmcntioneunder Penalty of Perjury that all inventory variations for <br />quarter. (moo in facility vete within the allowable limits for this <br />Coiumo i3 of the ioveacory Reconciliation Sheet) <br />❑ Inventory variations exceeded the allowable limits for this <br />hereby certify under penalty of <br />was not due to so Perjury that the source for quarter. I <br />unauthorized (leak) release. (Yes the variation <br />Laventory Reconciliation Sheet) in <br />Column 13 of the <br />List date, tank and amount <br />allowable limits_- for all variations that exceeded the <br />Date Tank / <br />Amount <br />1. <br />2_ -� <br />3. <br />4_ <br />5. <br />Additional dates/amouots 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 <br />within 24 hours and an unauthorized release report submitted. <br />Health <br />The quarterly summary report <br />quarter_ shall be submitted within 15 days of the end of each <br />Quarter I - January --) March <br />Quarter 2 - April --> <br />_ - - June <br />eQuarter 3--_ Juty -Sept <br />emner <br />( Quar[cr 4 - October ------ , <br />--> Dccembci \ <br />Send to: SAN JOAQUIN LOCAL HEALTH DISTRICT <br />1601 E. I:azelLon, P.O. Box 2009 <br />CT 40 10/86 Stockton, CA 95201 466-6761 <br />