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INVENTORY RECONCILIATION <br />QUARTERLY SUMMARY REPORT FORM <br />Facility Name: <br />Facility Address: /50a AJ <br />Telephone: Sc�y! oily <br />Person Filing <br />Report <br />I <br />19�� <br />flGl 1 - <br />Tank I Site Product <br />/ /Loon So /I SIC9.2 <br />z <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 13 of the Inventory 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 oat due to as unauthorized (leak) releaae. (Yes in Column 13 of the <br />Inventory Reconciliation Sheet) <br />List date, tank /, and amount for all variations Chat exceeded the <br />allowable limits. <br />Date Tank / Amount <br />1. <br />2. <br />3. <br />4. <br />S. <br />Additional dates/amounts :Fall be continued on a acparate 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 11calth <br />within 14 hours and an unauthorited release report submitted. <br />The Quarterly sum ry report shall be Rubmicced within 15 days of the end of each <br />Quartrr- <br />Quarter 1 - January --) March <br />lar <br />Ju Ly --) .lrpCC'nhrr <br />Quarter 4 - October -- Decrmber <br />Send to: SAN JOAQUIN LOCAI. HEALTH DISTRICT <br />1601 E. Hazcltnn• P.O. Rox 2009 <br />Stockton. CA 95201 466-6161 <br />LILT 4D 10/86 <br />