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INVENTORY RECONCILIATION <br />QUARTERLY SUMMARY REPORT FORM <br />Facility Name: <br />Facility Address: :;I- <br />Telephone: <br />Person Filing <br />Report„ <br />Tank I Size Product <br />/ <br />2-0-.,9 e., <br />v <br />1 hereby certify under penalty of perjury that all inventory variations for <br />the above meocioned facility were within the allowable limits for this <br />quarter. (No in Column 13of the IovenCory Reconciliation Sheet) <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 not due to an unauthorized (leak) release. (Yes in Column 13 of the <br />Inventory Reconciliation Sheet) <br />List date, tank /, and amount for all variations that exceeded the <br />allowable limits. <br />Date Tank / Amount <br />z. <br />JAN' 2 3 089 �J <br />4_ PERMIT /SERVICES <br />5. <br />Additional dates/amounts shall be continued no 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 Ilcalth <br />within 24 hours and an unauthorized release report submitted. <br />The quarterly sus a ry report shall be submitted within 15 days of the end of each <br />quarter_ <br />Quartrr I - January --) March <br />QAA(ter 2 - April --) J ...... <br />Quarter 3 - Jul y ll' Member <br />garter 4 - October --) December <br />Send to: SAN JOAQUIN LOCAL HEALTH DISTRICT <br />1601 E. Idazcll(tn, P.O. Bi)x 2009 <br />Stockton, CA 95201 466-61b1 <br />UCT 40 10/86 <br />