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� 'N \g qj <br /> INVENTORY RECONCILIATION <br /> QUARTERLY SUMMARY REPORT FORM <br /> Facility Name: G 6 /1? ✓�- tank / Size Product <br /> Facility Address: ROI( 3w>Y G �� <br /> G.I, tG <br /> Telephone : �- <br /> Person Fi i g <br /> Report 1y)14 'T/i✓ %b4"�^� <br /> m/L 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 caluma 13 of the inventory Reconciliation Sheet) <br /> E] 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 i, and amount for all variations that exceeded the <br /> allowable limits. <br /> Date Tank It Amount <br /> 1. <br /> 2. <br /> 3. <br /> 4. <br /> 5 <br /> Additioaal dates/amouats shall be continued oo A separate sheet of <br /> paper and attached". <br /> If the source of the variatioa'.which. c�ceeded all owable limits was due to <br /> a leak -theincident shall. be reported to S .J .L.H . D. n <br /> , Enviromental Health <br /> W ithin 24 hours aad anunauthorized release report submitted. - - <br /> The quarterly summary report shall be submitted within 15 days of the end of each - <br /> quarter. <br /> - - Quarcer I --. JanawryHarch <br /> Qaartcr 2 - April - --> June - <br /> Quarter 3 - July --) Scptcmb(!r <br /> Quarter 4 - October --) December . <br /> Send to= SAN JOAQUIN LOCAL HEALTH OISTRIC-1. <br /> 1601 F. . Hazelt "ll . P .O . Box 2()09 <br /> Stockton , CA 95201 466 -676L <br /> RC1- 40 10/86 <br />