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f <br /> INVENTORY RECONCILIATION <br /> QUARTERLY SUMMARY REPORT FORM <br /> Facsl,itF Names M '0/n Tank i Size. <br /> Product <br /> F:cilitr:Addresss - f ,� / <br /> C n/ C <br /> e2a/ <br /> Telephone : _ U <br /> Person Filingg.� <br /> Report 1-�(70VJ)AI <br /> 0 1 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 Loventory Reconciliation Sheet) <br /> Inventory variations exceeded the allowable Limits for tbis quarter. I <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 i, and amount for all variations that exceeded the <br /> allowable limits. <br /> 1 <br /> Date Tank E Amount <br /> 1. <br /> - )0--,3 1 -f- l l F <br /> 2. - ic,_ 7 l _ 199 <br /> 3. s- <br /> 4. <br /> �- <br /> Additional dates/amounts shall be continued on a separate sheet of <br /> paper and attached. <br /> Lf the source of the variation which- exceeded al-lowabLe limits was due to <br /> a leak the incident shall be reported to S .J . L.H . D . EnviraruDenta L Hea l th <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 --) Harch <br /> Quarter Z - April --> June <br /> Quarter 3 - July --> Septemhcr <br /> Quarter 4 - October --) [kcember <br /> Send to: SAN JOAQU IN LOCAL HEALTIi DISTRICT <br /> 1601 E. haze 1 lc►rt . P . O . lacy 2009 <br /> Stockton ,- CA 95201 466-6781 <br /> CT 40 10/86 = <br />