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INVENTORY RECONCILIATION <br /> QUARTERLY SUMMARY REPORT FORM <br /> Facility Name: r'«o c5l—kne� r_ 1 Tank f Size <br /> T Product <br /> Facility Address: <br /> tuna ✓c{. - •e�e <br /> C <br /> Telephone : <br /> Person Fili / <br /> Report <br /> c <br /> 1: 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 D 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 f, and amount for all variations that exceeded the <br /> allowable limits. <br /> Date Tank f Amount <br /> E <br /> 2. V I <br /> ? 9987 i <br /> ]. ENVIRO�t,�T <br /> HEA <br /> 4. FERMITISERVICSLTy <br /> 5. <br /> Additional dates/amounts shall be continued on a sevarate sheet of <br /> paper and attached. <br /> If the source of the variation which. esceeded allowable limits was due to <br /> a leak the incident shall be reported to S .J . L . H . D . EnvironmentaL Health <br /> within 24 hours and an unauthorized release report submitted_ <br /> The Quarterly summary report shall be submitted within 15 days of the end of each <br /> quarter. <br /> Quarter I - January --) March <br /> Quarter 2 - April --> Jane <br /> Quarter J - Ju I --) September <br /> Quarter 4 - October --) December <br /> Seod to: <br /> SAN JOAQUIN LOCAL HEAL1'li DISTRICT <br /> 1601 E . 1!azc1I (un , P .O . Box 2009 <br /> SLockcon , CA 95201 466 -67b1 <br /> 11;'I' 40 II1/ Nh <br />