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INVENTORY RECONCILIATION � <br /> QUARTERLY SUMMARY REPORT FORM <br /> Lraeiiity Names _Eb <" ✓- Tank I Stze Product <br /> Facility Address: <br /> Telephone : AIL - qC�� 000 L�3 <br /> Person Filing •Y <br /> Report _lo <br /> 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 I3 of the Inventory Reconciliation Sheet) <br /> ElInventory 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 13 of the <br /> Inventory Reconciliation Sheec) <br /> List date, tank 1, and amount for all variations that exceeded the <br /> allowable linics. <br /> Date Tank / Amount c6� <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 Hca Ith <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 /> qA 2 - April --) June <br /> Quarter 3 July --) September <br /> Quarter 4 - October --) December <br /> Send to: SAN JOAQUIN LOCAL HEALTH D1STRICT <br /> 1601 E . Hazelton . P .O . Box 2009 <br /> S[ockton . CA 95201 466-6761 <br /> UCT 40 10/ 86 <br />