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INVENTORY RECONCILIATION <br /> QUARTERLY SUMMARY REPORT FORM <br /> Fac.WtF_ Names � Tank Si5L'�"Z <br /> Product <br /> /�� - <br /> Facility�Addresss z/ ? Al � � , "L� <br /> 64.5Telephone : ('- 41-/ 2-6rl-- r �u- <br /> Person Filing <br /> Report <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 /> Inventory variations exceeded the allowable limits for this quarter. I r <br /> hereby certify under penalty of perjury that the source for the variation <br /> vas not due to an unauthorized (leak) releise. (Yes in Column 13 of the <br /> Inventory Reconciliation Sheet) _ <br /> List date, tank /, and amount for all variations that <br /> allowable limits. <br /> Date Tank f Amount <br /> Z. '� / — SU E,%VtoNIEMTAL HEALTH <br /> MITAERVICES, <br /> 3. tl / � <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 1 - January --> March <br /> Quarter 2 - April --> Jure <br /> Quarter 3 - July --> Septemh<!r <br /> Quarter 4 - October --) lkcember <br /> Send to: SAN JOAQUIN LOCM. HEALTH DISTRICT <br /> 1601 E. (faze 1 t<►n , P .O . Box 2009 <br /> Stockton ,- CA 95201 466-61bl <br /> CT 40 10/66 <br />