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INVENTORY RECONCILIATION 0 <br />QUARTERLY SUMMARY REPORT FORM <br />Facility Name: <br />'� d, <br />Tank i Size <br />Product <br />Fac icy Address: <br />L/ "7 <br />Telephone: <br />; /_ y/17 <br />8®✓ <br />Person Filing <br />Report I'� �t� <br />� 1 4r <br />14 I hereby certify under penalty of perjury <br />that all inventory variations <br />for <br />the above mentioned facility were within the allowable limits for this <br />quarter. (No <br />in Column 83 of the Inventory <br />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 duc�to an unauthorized (leak) release. (Yes in Column 13 of the <br />Inventory Reconciliation Sheet) <br />List date, tank i, and amount for all variations that exceeded the <br />allowable limits. <br />Date Tank I Amount <br />2. <br />3. <br />4. <br />S. <br />Additional dates/amouats 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 summary report shall be submitted within 15 days of the end of each <br />quarter. <br />Quarter B - January Harch <br />Q+iartcr 2 - April --> June <br />Quar _ 3 - July --> September <br />Qu a r t e r - October --> December <br />Send to: SAN JOAQUIN LOCAL HEALTH DISTRICT <br />UCT 40 10/86 <br />1601 E. Hazelton, P.O. Box 2009 <br />Stockton, CA 95201 466-6781 <br />.,.. __. �...-. :._ .:.�,•�.. ,>.-:: ..-Wit•,.,•.,..,_ <br />