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INVENTORY RECONCILIATION <br /> QUARTERLY SUMMARY REPORT FORM <br /> Facility. Names zi/i ) moi/ ���� Tank I Size. <br /> Product <br /> Facility'Wdresst /o C)oo. 4 <br /> Y '/0 0 00. <br /> D 0oc <br /> Telephone : 0 9L1/:z(9V <br /> Person Filing <br /> Report <br /> 0 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 is Column 13 of the Inventory Reconciliation Sheet) <br /> Inventory variations exceeded the allowable limits for this quarter. I P <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 f, and amount for all variations that exceeded the <br /> allowable limits. <br /> Date Tank f Amount <br /> 2. <br /> 3. <br /> 4. <br /> 5. <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 I - January --) March <br /> Quarter 2 - A p r i l --) June <br /> Quarter 3 - July --) September <br /> Quarter 4 - October --> December <br /> Send to: SAN JOAQU IN LOCAL HEALTH DISTRICT <br /> 1601 E . Haze 1 L cin , P . O . lacy 1009 <br /> Stockton , CA 95201 466 -67b1 <br /> 1(:T 40 10/86 <br />