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INVENTORY RECONCILIATION <br /> 1 <br /> QUARTERLY SUMMARY REPORT FORM <br /> Facility, Name: <br /> Tank i Size Product <br /> _ y _ <br /> Telephone : <br /> Person Filing <br /> Report (S A-w� 1- <br /> VA 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 /> i <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 /> vas not due to an unauthorized (leak) release. (lies in Colusan 13 of the <br /> Inventory Reconciliation Sheet) <br /> List date, tank !, and amount for all variations that exceeded the <br /> allowable limits. <br /> Date Tank f Amount <br /> 1. <br /> 2. <br /> 3. <br /> 4. <br /> 5. <br /> Additional dates/amounts shall be continued on a separate sheet of <br /> paper and attached. <br /> 1 If the source of the variation which. exceeded al'lowabte limits was due to <br />? a leak the incident shall be reported to S ,J . L.Ii . D. Environmental Health <br /> within 24 hours and an unauthorized release report submitted. <br />'i <br /> The Quarterly summary report shall be submitted within 15 days of the end of each <br /> quarter_ <br /> Quarter 1 - January --} March • <br /> Qgiarter 2, - April --> June • <br /> E; Quarter 3 - July --> Septemher <br /> Quarter 4 - october --> December <br /> • Send to: SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. Haze) t riot , P .O . fi<)x 2()()g <br /> ll(;T 40 10/86 Stockton , CA 95201 466-6761 <br />