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INVENTORY RECONCILIATION <br /> QUARTERLY SUMMARY REPORT FORM <br /> >FaciLitT Name: Tank I Site ct <br /> ao <br /> !'acility;Addreset 122 o w! <br /> 7-7 i <br /> Telephone : �9 c -Person Filing <br /> Filing ` <br /> Report V,/— <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 /> 1__L Inventory variations exceeded the allowable limits for this quarter. I <br /> hereby certify under penalty of perjury that the source for the variation <br /> vas not clue to as unauthorized (leak) cele se. (Yes is 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 tank f Mount <br /> 1. <br /> 2. <br /> 3. <br /> 4. <br /> s. <br /> A44itional dates/amounts shall be continued on a separate sheet of <br /> paper and attached. <br /> If the source of the variation which. exceeded at•lovabLe limits was due to <br /> a leak the incident shall be reported to S „J ,L.H .D. Envirocunental Ucalth <br /> within 24 hours and an unauthorised release report submitted. <br /> The quarterly summary report shall be submitted within 15 days of the end of each <br /> quarter. <br /> Quarter 1 - January --) March ` / <br /> r - April June <br /> Quarter l - July --) September <br /> Quarter 4 - October --) December <br /> Send to: SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 K. Ilaze I L+lti , P .O . Box 2009 <br /> SLdckton . CA 95201 466-6761 <br /> UGT 40 10/ 86 <br />