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INVENTORY RECONCILIATION <br /> QUARTERLY SUMMARY RFPORI FORM <br /> Facility Name-_ -.7 <br /> Tank I Site <br /> Product <br /> Facility Addre•.: /(�j <br /> LtJ <br /> Sltl gK z>rJ <br /> Telephone : 41,2 <br /> Person Fig <br /> Report <br /> 1K1 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 1]of the loventory 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 ivariation <br /> was not due to An unauthorized (leak) release. (Yes—' in Column IJ of the <br /> Inventory Reconciliation Sheet) <br /> List date, tank t, And amount for all variations that exceeded <br /> Allowable limits_ the <br /> Datc Tank f Amount <br /> 1_ <br /> 2. <br /> 3. <br /> 4. <br /> 5. <br /> Additional dates/amounts shall be continued on ■ separate sheet of <br /> Paper and attached. <br /> If the source of the variation vhich. exceeded allowable Limits was due to <br /> a leak the incident shall be reported to S.J .L.H. D. Environmental Uealch <br /> within 24 hours and an unauthorized release report submitted. <br /> The Quarterly summary report shall be xubmitced within 15 days of the end of each <br /> quarter. <br /> Quarter 1 - January --> March <br /> Quarter 2 - April --) June <br /> Quarter l - July --> September <br /> Quarter 4 - October --> December <br /> Send CO: SAN JOAQUIN LOCAL HEALT[i DIS-1'R1CT <br /> L601 E . Ilaze l t nn - 1, .0 . Ito.c 2009 <br /> IGT 40 10/86 Stockton . CA 95201 466-6161 <br />