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INVENTORY RECONCILIATION <br /> QUARTERLY SUMMARY REPORT FORM <br /> Facility Name: v1 / o"C/ Tank # Size Product <br /> o0o Ga . sol:aP <br /> Facility Address: A l►"f �f <br /> Am eca a. C16a 3(o <br /> Telephone : 3Q- '151, <br /> Person Filin <br /> Report vE/Y' J . We%Jodi <br /> QI 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 /> QInventory 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 Sheet) <br /> List date, tank #, and amount for all variations that exceeded the <br /> allowable limits. <br /> Date Tank # Amount f l r I =1 <br /> 3. <br /> 4. r'�111 <br /> 5. <br /> Additional dates/amounts shall be contiaued .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 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 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 DISTRICT <br /> 1601 E . HazelLo ll , P .O . BOx l()" <br /> Stockton , CA 95201 466-6751 <br /> UGT 40 10186 <br />