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INVENTORY RECONCILIATION <br /> QUARTERLY SUMMARY REPORT FORM <br /> Facility Name: � � 6C Tank i Size Product <br /> Facility Address: p 20 �y + <br /> Telephone : U3 Z©1\ <br /> Person Fi Lqg <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 13of 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 /, and amount for all variations that exceeded the <br /> allowable limits. <br /> Date Tank I Amount <br /> 1. <br /> 1. <br /> 3. <br /> 4. <br /> 5. <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 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 /> J,rtr <br /> er I = January --� March <br /> er 2 April --) June <br /> Quarter 3 - July September <br /> Quarter 4 - October --) December <br /> Send to: SAN JOAQUIN LOCAL HLALTH DISTRICT <br /> 1601 B . IlazelLon , P .O . Box 2009 <br /> Stociccon , CA 95201 466-6781 <br /> ucr 40 10/86 Out ��c�s �ss Cwa%` 1�" ' �� .. '' ' ` <br /> S�-DeAQ t-okl� CAT- <br />