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INVENTORY RECONCILIATION <br /> QUARTERLY SUMMARY REPORT FORM <br /> Facility Name: �, j ,� ,Z Tank # Size Product <br /> e 1/ - <br /> Facility Address: 1-3q9 '2 f,- fi d% <br /> Telephone : <br /> Person Filing <br /> Report � ✓ 7`' <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 /> QInventory variations exceeded the allowable limits for this quarter. I <br /> hereby certify under penalty of perjury that the source for the variation <br /> vas 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 <br /> 1. <br /> 2. <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 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 --> Hsrch <br /> Quarter 2 - April =_> June <br /> Quarter 3 - July --> September <br /> Quarter 4 October > December <br /> Send to: SAN JOAQUIN LOCAL HEALTH DISTRICT MAR 14 <br /> 1601 E . Hazelton , P . O . Box 2009 ENVlht'Mc "IAL HEALTH <br /> Stockton , CA 95201 466-6781 VERW-1/SE"VICLS <br /> UGT 40 10/86 <br />