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. t . <br /> INVENTORY RECONCILIATION <br /> QUARTERLY SUMMARY REPORT FORM <br /> FaciLitr Name: mow ' ° Tank # Size product <br /> 77/7,75 <br /> Facility Address: �/ O <br /> Telephone <br /> Person Filing - <br /> I hereby certify under penalty of perjury that all inventory variations for <br /> the above mmationed facility were within the allowable limits for this <br /> quarter. (No in Column 13of the inventory Reconciliation Sheet) <br /> Inventory variations exceeded the allovable 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 P.econciliation Sheet) <br /> List date, tank #, and amount for all variations that exceeded the <br /> allowable limits. <br /> Date Tank f Amntir�t <br /> 1. <br /> 2. <br /> 3. <br /> 4. <br /> S. <br /> Additional dates/amounts shall be continued on a separate sheer 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 Health <br /> Within 24 hours and an unauthorized release report submitted. <br /> The quarterly sugary report sh::ll b,e submitted within 15 days of the end of each <br /> quarter. <br /> Quarter I - January --) Narch <br /> Q,sartcr 2 - April --> Jur+e <br /> Quarter 3 - July september <br /> Quarter 4 - October <br /> Send to: SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E . Haze 1 t r et . P .O . BOx 2()()9 <br /> SLockton . CA 95201 466--6781 <br /> IIc;T 40 10/ 86 <br />