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INVENTORY RECONCILIATION <br /> QUARTERLY SUMMARY REPORT FORM <br /> Facility Name: �WTank rtE Size AFroduct <br /> Facility Address: <br /> Telephone : <br /> Person F in <br /> Report <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 13 of the Inventory Reconciliation Sheet) <br /> ElInventory 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) release. (Yes in Column 13 of the <br /> Inventory Reconciliation Sheet) <br /> List date, tank 1, and a=unt for all variations that exceeded the <br /> allowable liinits. <br /> Date Tank f Amount <br /> 1. <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 al-lowable limits was due to <br /> a leak the incident shall be reported to S .J . L . H . D . Environmental liealth <br /> within 24 hours and an unauthorized release report submitted. <br /> The quarterly summary report shall be Fubmitted within 15 days of the end of each <br /> quarter. <br /> Qu:.rter I - January --) March <br /> QQiartcr 2 - April --> .lune <br /> Garter 3 - July --) Septcmh(:r <br /> Quarter 4 - October --) December <br /> Send to: SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 l: . Hazelton . P .0 . Box 2009 <br /> Stockton , CA 95201 466 -67b1 <br /> Uc;T 40 10/ 80 <br />