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INVENTORY RECONCILIATION - <br /> QUARTERLY SUMMARY REPORT FORM ENVIRWE•:TAL HEALTH <br /> FER'ALTrc�,�:ylrES <br /> Facility Name: Tank I Sire Product <br /> 7- DDD E OA-f- <br /> Faeility�Addresa: $D-�'ZY/sTi�✓9� <br /> Telephone : zrj9- 9BZ —Ot D d <br /> Person Filin <br /> Report <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 not due to an unauthorized (leak) releise. (Yes in Column IJ of the <br /> Inventory Reconciliation Sheet) <br /> List date, tank i, and aaaount for all variations that exceeded the <br /> allowable limits_ <br /> Date Tank / Amount <br /> 1. <br /> 2. <br /> J. <br /> 4. <br /> S. <br /> Additional dates/a uotx 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 Ucalth <br /> within 24 hours and an unauthorized release report submitteil. <br /> The quarterly summary report shall be submitted within 15 days of the end of each <br /> quarter. <br /> Quarter I - January --) March <br /> Qaartcr© - April --> June <br /> Quarter J - July --) SepCemb'•r <br /> Quarter 4 - October --) Occember <br /> S d to: SAN JOAQUIN LOCAI, HEA1.11; DISTRICT <br /> 1601 K . Hazeltnn • P . O . Rnx 2009 <br /> StOctton . CA 95201 466 -67b1 <br /> 40 10/ H6 <br />