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INVENTORY RECONCILIATION <br /> QUARTERLY SUMMARY REPORT FORM <br /> Facility Name: ( �OW"c\ l � rank F Size Produc <br /> < Facility Address: p�� � � I OCG <br /> ckto.TC 171 4 7 2 v 2 <br /> Telephone : c{ lk� <br /> Person Fi >_nT—`nA �— <br /> Report _ Oan V v1\h �J" <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 /> E] 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 rank 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 /> 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 su. ry report shall be submitted within 15 days of the end of each <br /> quarter. <br /> Qua - -IJanuary --> March <br /> April --> .lune Igs'� <br /> Quarter 3 - July --> September <br /> Quarter 4 - October --> December <br /> Send to: SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E . Ha7_OlCon , P .O . Box 2009 <br /> SCockton , CA 95201 466-6781 <br /> UGI' 40 10/86 0�-kN VAC, COPY <br /> '7- In ck-\).� �r <br />