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6 <br /> INVENTORY RECONCILIATION <br /> QUARTERLY SUMMARY REPORT FORM <br /> r <br /> Facility Name: �i✓[JLeTF— /iy[ . <br /> om_ <br /> Facility Address: <br /> �AAra.414 <br /> Telephone : 1zo�� Z3ti c`3100 <br /> Person Filing <br /> Report �- . mow <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 /> ❑ 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 sa unauthorized ( leak) release. (Yes in Column 13 of the <br /> Inventory Reconciliation Sheer) <br /> List date, tank f, and amount for all variations t <br /> allowable limits. that exceeded the <br /> Date Tank I 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 allowable limits was due to <br /> a leak the incident shall be reported to S ,J .L . H. D. Environmental Ncalth <br /> W <br /> ithin 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 1 - January --) March <br /> Quarter 2 - April --> June <br /> Quarter 3 - July --> September <br /> Quarter 4 - October --> December <br /> Send to: SAN JOAQUIN LOCAL HEALTH DISTRIC1' <br /> 1601 F . Hazelton , P .O . Box 2009 <br /> iiGT 40 10/86 Stockton , CA 95201 466-6781 <br />