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INVENTORY RECONCILIATION <br /> QUARTERLY SUMMARY REPORT FORM <br /> Facility Name: Z11 <br /> 2IP61-1. Tank I Size oduct <br /> DO <br /> Facility Address: <br /> _ 11714PI5. <br /> ,3 - - <br /> Telephone : <br /> Person F41, ing <br /> Report ,,4- <br /> EJI 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 13of the Inventory Reconciliation Sheet) <br /> E] 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 ao unauthorized (leak) release. (Yes in Column 13 of the <br /> Inventory Reconciliation Sheet) <br /> List date, tank f, and amount for all variations Chat exceeded the <br /> allowable limits. <br /> Date Tank f Amount <br /> i. <br /> 2. <br /> 3. <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 summ,ry report shall be submitted within 15 days of the end of each <br /> quarter. <br /> Qu:.rtcr I - January --> H.,rch <br /> Q,jartcr 1 - April --> Julie <br /> Quarter 3 - July --> Septcmher <br /> Quarter 4 - October --> lk_cember <br /> Send to: SAN JOAQU IN LOCAL HEALTH DISTRICT <br /> L601 I: . 1!azc• 1 I (,n . P .0 . Ro x 1009 <br /> Stockton , CA 95201 466 -6761 <br /> LIGT 40 10/ 90 <br />