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INVENTORY RECONCILIATION <br /> QUARTERLY SUMMARY REPORT FORM <br /> 7/s/,r9 <br /> Facility Name: �' L Kam "y 2T&nkf <br /> Size Product <br /> Facility Address; 0 )_117#z ew �1EL <br /> Telephone : — — <br /> Person Filin � ��3-�yS7 <br /> Report 6,11 /4,'�ZerA <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 an unauthorized (leak) releise. (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 R Amount <br /> _. <br /> 3. <br /> 4. <br /> S. <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 <br /> within 24 hours and an unauthorized release report sDubmittedonmental Health <br /> The quarterly summary report shall be submitted within 15 days of the end of each <br /> quarter. / <br /> Quarter I - January --> March . <br /> /// !J April --> June <br /> arte July --) September <br /> !Jrte <br /> 4 - October --) December <br /> Send to: SAN JOAQUIN LOCAL HEAL1'li DIS'1'HIC'1' <br /> 1601 E . llazelLon , P .O . Hos 2009 <br /> 40 10/H6 Stockton , CA 95201 466-6781 <br /> ' <br />