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INVENTORY RECONCILIATION <br /> QUARTERLY SUMMARY REPORT FORM <br /> Facility Name : <br /> Tank # Size Product <br /> Facility Address :,l����, o��, ��z <br /> Telephone : <br /> Person Fi <br /> Report : <br /> [ ] I Hereby certify under penalty of perjury that all inventory <br /> variations for the above mentioned facility were within the allowable <br /> limits for this quarter. (No in Column 13 of the Inventory <br /> Reconciliation Sheet ) . <br /> Inventory variations exceeded the allowable limits for this quarter. <br /> I hereby certify under penalty of perjury that the source for the <br /> variation was not due to an unauthorized ( leak) release . ( Yes in <br /> Column 13 of the Inventory Reconciliation Sheet ) . <br /> List date, tank # , and amount for all variations that exceeded the <br /> allowable limits . <br /> Date Tank # Amount <br /> D g & <br /> 2 . NOV n 1988 W <br /> 3 . <br /> 4 . ENVPERMl7�!SEE?`J{�EENTAL ALTH <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 <br /> to a leak the incident shall be reported to S.J.L. H. D. Environmental <br /> Health within 24--hours and an unauthorized release report submitted. <br /> The quarterly summary report shall be submitted within 15 days of the <br /> end of each quarter. <br /> Quarter 1 - January --> March <br /> Quarter 2 - April --> June <br /> Quarter 3 - July --> September <br /> Quarter 4 - October --> December <br /> Send to : SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. Hazelton, P. 0. Box 2009 <br /> Stockton, CA 95201 466-6781 <br /> T 40 10/86 <br />