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INVENTORY RECONCILIATION <br /> QUARTERLY SUMMARY REPORT FORM <br /> EacWty. Names _ ,OzG ��� /�� � Tank I Size Product <br /> FaCMAX-'Address: — / <br /> Telephone : <br /> Person Filin vv� <br /> Report �Ai3l <br /> I 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 I3 of the Inventory Reconciliation Sheet) <br /> r� <br /> Inventory variatibas 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 as unauthorized (leak) releise. (Yes in Column 13 of the <br /> Inventory Reconciliation Sheet) <br /> List dater tank it and amount for all variations that exceeded the <br /> allowable limits. <br /> Date Tank ! Amount <br /> los— <br /> e. -'11,2-71s7 0-7----� 93— v -e -307-.-2 75-t- <br /> 3. <br /> 4. 5/i /973o I-� ins- 5/9G 308 <br /> 5. `/a-7/87 30-7- 1 -P75— <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 I - January --) March <br /> 1✓Quarter 2 - April --> June <br /> Quarter 7 - July --> September <br /> Quarter 4 - October --> December <br /> Send to: SAN JOAQUIN LOCAL HEALTH DIS-1'RiCT <br /> 1601 E. ItaZeIL011 , P .O . Box 2009 <br /> Stockton , CA 95201 466-6761 <br />