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INVENTORY RECONCILIATION,.-, <br />QUARTERLY SUMMARY REPORT FORM <br />Facility Name: <br />t 3 <br />Fac- ity Address: <br />Telephone: <br />Person Fit <br />Re ortr\ <br />Q/1 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 />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 amount for all variations that exceeded the <br />allowable limits. <br />Date Tank # Amount <br />1. <br />2- <br />3. <br />4. <br />5. <br />Additional dates/amounts shall be continued on 2 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 summary report shall be Submitted within 15 days of the end Of each <br />quarter, <br />Quarter I <br />- January <br />March <br />Quarter 2 <br />- April <br />June <br />Quarter 3 <br />- July <br />Septembcr <br />Quarter 4 <br />- October <br />December <br />Send to: SAN JOAQUIN LOCAL HEALTH DISTRICT <br />1601 E. liazelton, P.O. Box 2009 <br />LICT 40 10/86 Stockton, CA 95201 466-6781 <br />