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INVENTORY RECONCILIATION <br /> QUARTERLY SUMMARY REPORT FORM <br /> Facility Name;PGjyfjJj/ � - Tank 1 Sice Product <br /> Facility Address: 9-0 <br /> Telephone : G) <br /> Person Filin <br /> Report 4 IL <br /> nI hereby certify under penalty of perjury that all inventory variations for <br /> the above mentioned facility were within thl allowable Limits for this <br /> quarter. (No in Column I7 of the inventory Reconciliation Sheet) <br /> 0 Inventory variations exceeded the allowable limits for this quarter. L <br /> hereby certify under penalty of perjury that the source for the variation <br /> was not due to as unauthorized (leak) release. (Yes in Column IJ of the <br /> Inventory Reconciliation Sheet) <br /> List date, tank Ir and amount for all variations that exceeded the <br /> allowable Limits. <br /> Date Tank ! Amount <br /> - .3 _ <br /> 2. <br /> 7. <br /> 4. <br /> s. �SP,P ? ^ fR? <br /> ENVIEEkRRUM1E;vTAL HEALTH <br /> Adrattanal �zte^lz=ugts shall be continued on a separate shee of /SERVICES <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 Ilcalth <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 --) March <br /> QIiarter 2 - April --) June of <br /> Quarter ) - July --) Septemher 0 <br /> Quarter 4 - October --) Ikcemher 1� <br /> Send to: SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. . Hazel ( (,n . I' .O . Rir !1111') <br /> Stockton ;. CA 95201 466 -67bl <br />