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LNYENTORY RECONCILIATION ppR 1 <br /> QUARTERLY SUMMARY REPORT FORM <br /> EN��PERtJ!IS I S��2V1C;�:.S <br /> Facility Name: 2, 9 Tank f Size oduct <br /> O <br /> Facility Address: <br /> Telephone,-, / <br /> Person Filin <br /> Report <br /> ElI 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 lovencory Reconciliation Sheet) <br /> Inventory variations 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) releise. (Yes in Column 13 of the <br /> Inventory Reconciliation Sheet) <br /> List date, tank 1, and amount for all variations that exceeded the <br /> allowable limits. <br /> Date Tank I Amount <br /> 2- <br /> 3. <br /> G. <br /> 5. <br /> Additional daces/amouacs shall be continued on a separate sheet of <br /> paper and accached. <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 11calth <br /> WiChin 24 hours and an unauthorized release report submitted. <br /> The quarterly su—,cy report shall be %ubmicccd within 15 days of the end of each <br /> quarter_ <br /> Qu:.rcer i - .January --) Harch <br /> Qsarcer 2 - April --> June <br /> Quarter ] - .July --> SepCemh(:r <br /> Quarter 4 - October --> December <br /> Send co: SAN JOAQU IN I.0CAL HEALTH DISTRICT <br /> 160L E. Haze l t (ln . P .O . Box 2009 <br /> SLockcon , CA 05201 460 -67b1 <br /> LICT 40 10/ 80 <br />