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INVENTORY RECONCILIATION <br /> ,tQUARTERLY SUMMARY REPORT FORM <br /> irseLUty. Nass: , 1� / / Tank F Size. Product <br /> taeility:Alddress: <br /> Telephone : <br /> �r�J�3 ) <br /> Person Fil ng <br /> Report <br /> 0 1 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 13of the lovectory Reconciliation Sheet) <br /> ,1 <br /> r� <br /> m <br /> Inventory varistibas exceeded the allowable limits for this quarter. ' I <br /> bereby certify under pesaLty of perjury that the source for the variation <br /> was not due to an usauthorixed (leak) releise. (Y-es in Column 13 of the <br /> Inventory Reconciliation Sheet) <br /> List dates task /, and amount for aLl variations that exceeded the <br /> allowable Limits. <br /> Date Tank / Amount <br /> 1. 5 ��— lJ <br /> a)7—A- <br /> 2. <br /> ) —2. S- 30/�- 7h/f <br /> 4. <br /> Additional dates/amounts shall be continued on a separate sheet of <br /> paper and attached. <br /> If the source of the variation uhich. exceeded allowable Limits was due to <br /> a leak the incident shall be reported to S ,J .L.N.D. Environmental Health <br /> within 24 hours and an unauthorised 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 /> Quarter 2 - April June <br /> Quarter 3 - July --> September <br /> Quarter 4 - October --> December <br /> Send to: SAN JOAQUIN LOCAL HEALTH UIS'l'RICT <br /> 1601 E. 1i3ZCl1 tO,, . P .O . Box 2009 <br /> Stockton . CA 95201 466-6761 <br /> ;T 40 10/86 <br />