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i R <br /> INVENTORY RECONCILIATION <br /> QUARTERLY SUMMARY REPORT FORM <br /> Lac i Lity Ham: <br /> Tank Size Product <br /> / - <br /> 4Z 11-,042 <br /> e <br /> lacility Address: q <br /> Telephone : a, � <br /> Person Filing <br /> Report '`fin ,,-lea_¢r`c <br /> L hereby certify under penalty of perjury that all inventory variations for <br /> the above oentioned facility were within the allowable limits for this <br /> quarter. (Ko is Column 13 of the inventory Reconciliation Sheet) <br /> Laventary 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 so unauthorized (leak) release. (Yes in CoLumn 13 of the <br /> inventory Reconciliation Sheet) <br /> List date, tack 1, irnd amount for all variations that exceeded the <br /> allowable limits. <br /> Date Tank # Amount <br /> 1. <br /> 3. - <br /> 4. <br /> 5. <br /> Additional dates/amounts shall be continued on a separate sheet of <br /> I-- <br /> paper and attached. .'7 <br /> Ll <br /> to ct 2 <br /> LE the source of the varix[ion which. rxceedcd allowable Limits was due to - -, <br /> a leak the incident shall be reported to S .J .L .H , D. Environmental dcalth _ < i.L1 <br /> 11i[hin 24 hours and an unauthorized re Lease report submitted. <br /> The quarterly summary report shall be Kubmit[ed within 15 clays of the end of caP, <br /> .quarter. <br /> Quarter I - January --> March �- <br /> QrAarter 2 - April --> June <br /> Quarter 3 - July --) Septembr.r <br /> Quarter 4 - October --> ikcember <br /> Send to: SAN JOAQUIN LOCAL HEALTH UIS'1'ttlC•1• <br /> 160L K . i:azc 1 L 4)11 , <br /> Stockton , CA 95201 466-67bL <br /> V 40 10/ Hh <br />