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INVENTORY RECONCILIATION <br /> QUARTERLY SUMMARY REPORT FORM <br /> Facility Name; <br /> --- 02/D Tank / Size Product <br /> lacility Addresat <br /> hone : <br /> Tele <br /> � p ao S 3 ss� G ro c'� <br /> Person Filittt;g <br /> Report <br /> I hereby certify under penalty of perjury that all inventory variations for <br /> the above mentioned facility were within the allowable limits for thio <br /> Quarter. (No in Column U of the Inventory Reconciliation Sheet) <br /> I <br /> 7 <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 <br /> not due to an unauthorized (leak) release. (Yes in Column 13 of the <br /> Inventory Reconciliation Sheet) <br /> i <br /> List date. tank /r and amount for all variations that exceeded the <br /> allowable limits. <br /> Date Tank f Amount <br /> 2. <br /> I 3. <br /> 4. <br /> S. <br /> Additional dates/amounts shall be continued on a separate sheet of <br /> Paper and attached. <br /> If the source of the variation whichexceeded 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 <br /> Quarter. submitted withi IS days of he end of each <br /> Quarter I - January --) March <br /> Quarter Z - n <br /> July <br /> --) Jue <br /> l <br /> Quarter ) - July __) Se <br /> ptcmhcr <br /> Quarter 4 - october --) I>rcember <br /> JAN 61989 <br /> Send to: SAN JOAQUIN LOCAL HEALTH OISTRIC'1' tvIENTAL <br /> 1 601 F . 11azc 1 tun , P . 0 . Itux 2()()9 ENVIR0NITISERVICESPERM <br /> LTH <br /> IGT 40 10/86 Slockr.on , CA 95201 466-6761 <br />