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INVENTORY RECONCILIATION <br /> QUARTERLY SUMMARY REPORT FORM <br /> Facility Name: r014 d Tank I size Product <br /> Facility Address: <br /> astece Cd. 3 <br /> Telephone : t-�20`T`` <br /> Person Filing _ <br /> Report ,T�,°/'/'� U. Wo ' <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 /> IIInventory 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 (teak) release. (Yes in Coluzan 13 of the <br /> Inventory Reconciliation Sheet) <br /> List date, tank #, and amount for all variations that exceeded the <br /> allowable limits. <br /> Date Tank # Amount <br /> �/- <br /> 2. <br /> 3. <br /> 4. Ott ourA <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 Bea 1 th <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 /> Quarter 2 - April --> June <br /> Quarter 3 - July -- > September 4 <br /> Quarter 4 - October --> December , <br /> Send to: SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E . Haze I LO I[ , P .O . Sox 2009 <br /> Stockton , CA 95241 466-6781 <br /> UGT 40 14186 <br />