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INVENTORY RECONCILIATION <br />QUARTERLY SUMMARY REPORT FORM <br />Facility Name: <br />T _ <br />Facilit <br />Telepho <br />Person <br />Report: <br />Tank # Size Product <br />0 <br />I Hereby certify under penalty of perjury that all inventory <br />V <br />ariations 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 />a� <br />2. <br />.y <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 <br />1 <br />- January --> <br />March <br />Quarter <br />2 <br />- April --> <br />June <br />Quarter <br />3 <br />- Jul,y --> <br />September <br />Quarter <br />4 <br />- October <br />December <br />Send to: <br />SAN JOAQUIN <br />LOCAL HEALTH DISTRICT <br />1601 E. Hazelton, P. 0. Box 2009 <br />Stockton, <br />CA 95201 466-6781 <br />T 40 10/86 <br />