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a <br /> saw <br /> INVENTORY RECONCILIATION <br /> QUARTERLY SUMMARY REPORT FORM � `- <br /> // lHE STH <br /> Facility flame: Q. �l / i Lckw�z. Itle, Tank Product <br /> Facility,'Address: F <br /> C 3 <br /> Telephone : 901 7- it S3 <br /> Person Filing . <br /> Report fit (CL- if <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 13 of 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 1, and amount for all variations that exceeded the <br /> allowable limits. <br /> Date Tank £ 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 summary report shall be submitted within 15 days of the end of each <br /> quarter. <br /> Quarter I - January --> March <br /> Q,iartcr 2 - April --> June <br /> Quarter 3 - July -_} September <br /> Quarter 4 - October --> (kkccmbcr <br /> Send to: SAN JOAQUIN LOCAL HEALTH 0ISTHICT <br /> 160L H , 1 azc 1 [ r►I1 , P . O . BO X M09 <br /> Stockton . CA 95201 466-6781 <br /> ;T 40 10/ 86 <br />