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INVENTORY RECONCILIATION July 6 0 �J <br /> QUARTERLY SUMMARY RFPORT FORM `s <br /> tiwlr Vill - t HEALT <br /> i Ehivpl N <br /> Facility Name: ���� �� ,� l/�nn Tank I Size <br /> Pro uct <br /> Facility Address: <br /> C � <br /> Telephone : <br /> Person Filing <br /> .,Report <br /> D(it 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 not due to an unauthorized (leak) release. (Yes in Column 13 of the <br /> Inventory Reconciliation Sheet) <br /> List date, tank I, and amount for all variations that exceeded the <br /> allowable limits. <br /> Date Tank / Amount <br /> 1. <br /> 2- <br /> 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 which exceeded allowable limits was due to <br /> A leak the incident shall be reported to S .J .L . H . D . Environmental Ilealth <br /> within 24 hours and an unauthorized release report submitted. <br /> nc Quarterly summary report shall be submitted within 15 days of the end of each <br /> Quarter. <br /> Quarter I - January --) march <br /> QQjartcr 2 - April --> June <br /> Quarter 1 - July __) September <br /> Q'.3rter 4 _ October --) December <br /> Send to: SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E . I:arc11 ,u1 , 1' . O . 14,x 1()()9 <br /> Stockton . CA 95201 466-67bl <br />; l:T 40 I0/86 <br />