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i.tVENTORY RECONCILIATION <br /> 1 QUARTERLY SUMMARY REPORT FORM <br /> Facility Nane: - Tank Size oduct <br /> Facility Address: <br /> 11A ) e2lZlpall— J2 e2zlwl',� <br /> Telephone <br /> Person F Pin <br /> Reporc <br /> I hereby certify under penalty of perjury that all inventory variatioas for <br /> the above mentioned facility were within the allowable limits For this <br /> quarter. (No in Colum 13 of the lavcatory Reconciliation Sheet) <br /> Inventory variatioas exceeded the allowable Limits for this 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 Coluzzn 13 of the <br /> Inventory Reconciliation Sheet) <br /> List date, Cank 1, and arsounc for all variations Chat exceeded the <br /> allowable limits_ <br /> Date Tank I Amount <br /> 1. <br /> 2_ <br /> 3. <br /> 4. <br /> S. <br /> Additional daces/aaouocs shall be continued on a separate sheet of <br /> paper and aCtached. <br /> If the source of the variation whichexceeded at lovable limits was due to <br /> a leak the incident shall be reporccd to S .J . L .H . D . Environmental Health <br /> within 24 hours and an unauthorized release report submitted. <br /> The quarterly summary report shall br nubmitted within 15 days of the end of each <br /> quarter. <br /> Qu:.rcer 1 - January --) Harch <br /> Q1sartcr 2 - April June <br /> Quarter 3 - July --) SePccmh(!r <br /> Quarter 4 - October --> December <br /> send co: SAN JOAQUIN 1.0CAI, HEALTH DISTRICT <br /> 1601 E . Naze 1 l c111 . P .0 . lice 2009 <br /> SLockCOn . CA 95201 466 -6781 <br /> U(:I' 40 10/86 <br />