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• a <br />INVENTORY RECONCILIATION <br />QUARTERLY SUMMARY REPORT FORM <br />Facility Name: C,bd,`�,��al lis D4Ta� <br />Facility Address; %S luoLcZ <br />Telephone: _..3 �4 _ _'3 <br />Person Filing <br />Report C1J l <br />I 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 />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 an unauthorized (leak) release. (Yes in Colum 13 of the <br />Inventory Reconciliation Sheet) <br />List date, tank /, and amount for all variations that exceeded the <br />allowable limits. <br />Date Tank f Amount <br />2. <br />3. <br />4. <br />S. <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 summary report shall be submitted within 15 days of the end of each <br />quarter. <br />Quarter 1 - January --i March <br />Quarter 2 - Atiri1 --> June <br />- July --> Septemb�-c <br />arter 4 - October --> lk-comber <br />Send to: SAN JOAQUIN LOCAL. HEALTH DISTRICT <br />1601 E. liaze l t c►n , P.0. Box 2009 <br />Stockton, CA 95201 466-67b1 <br />(;'1' 40 10/86 <br />