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ONYENTORY RECONCILIATION <br /> QUARTERLY SUMMARY REPORT FORM <br /> Facility ?tame: /./-- <br /> �,1--NLS Tank f Size _ Product <br /> Facility Address: <br /> Telephone : 20 9 <br /> Person Fi g _ <br /> Report <br /> r . 1 ; <br /> I hereby certify under penalty of perjury that all invento[',ii 'YatY <br /> the above mentioned facility were within the allowable limits' for�thiiss or <br /> quarter. (No in Column 13 of the inventory Reconciliation. �hee[1-„- - -- <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 Sheer) <br /> List date, tank 1, Rod amount for all variations that exceeded the <br /> allowable Limits_ <br /> Date Tank i <br /> _— Amount <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 al-lovable 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 --) Harch <br /> Q"arter 2 - April --> June <br /> Quarter J - July --> September <br /> Qiarter 4 - October --> December <br /> Send to: SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E . Hazelton , P . O [Sox 2009 <br /> UCT 40 10/86 Stockton , CA 95201 466-6781 <br />