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INVENTORY RECONCILIATION <br /> ( OV ff RLY SUMMARY REPORT FORM <br /> <YiiG�✓I'�i:i �1E-1 1 A,L 1 �i1L1 <br /> Facility Name( UI7IkFA �6 ,� ,,/ '0, Tank 11 Size Product <br /> Facility Address 0a <br /> Telephone: <br /> Person Filing Report: <br /> I hereby certify under penalty of perjury that all inventory variations for the <br /> above mentioned facility were within the allowable limits for this quarter. (No <br /> in column 13 of the Inventory Reconciliation Sheet.) <br /> Inventory variations exceeded the allowable limits for this quarter. I hereby <br /> certify under penalty of perjury that the source for the variation was not due <br /> to an unauthorized (leak) release. (Yes in column 13 of the Inventory Reconciliation <br /> Sheet) <br /> List date, tank f{, and amount for all variations that exceed the allowable <br /> limits. <br /> Date Tank # Amount <br /> 1. <br /> 2. <br /> 3. <br /> 4. <br /> 5. <br /> Additional dates/amounts shall be continued on a seperate sheet of paper <br /> and attached. <br /> If the source of the variation which exceeded allowable limits was due to a leak <br /> the incident shall be reported to S.J.L.H.D. Environmental Health within 24 hours <br /> and an unauthorized release report submitted. <br /> The quarterly summary report shall be submitted within 15 days of the end of <br /> each quarter. <br /> Quarter 1 - January—> March Quarter 2 - April—> June <br /> Quarter 3 - July—> September Quarter 4 - October—> December <br /> Send to: San Joaquin Health District <br /> 1601 E. Hazelton/P.O. Box 2009 <br /> Stockton, CA 95201 <br /> Ph# 466-6781 <br />