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III <br />y INVENTORY RECONCILIATION <br />QUARTERLY SUMMARY REPORT FORM <br />IF&cility Name: r. <br />Address:Facility <br />Telephone: <br />a <br />Person Filing <br />Report <br />. <br />� E M <br />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 13 of the Inventory Reconciliation Sheet) <br />Inventory variations exceeded the allowable limits for this quarter. 1. <br />hereby certify under penalty of perjury that the source for the variation <br />was not due to an unauthorized (leak) release. (Yes in Column13 of the <br />Inventory Reconciliation Sheet) <br />List date, tank f, and amount for all variations that exceeded the <br />allowable limits. <br />Date Tank Amount <br />1. <br />2. <br />3. <br />4. <br />-------------- <br />S. <br />Additional dates/amounts shall be continued on a separate sheet of <br />paper and attached. <br />reportedIf the source of the variation which- exceeded al-lowable limits was due to <br />a leak the incident shall be <br />Environmental <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 --> March <br />arter 2 -- April June <br />Quarter I - July --? September <br />Quarter 4 - October --> lk:cember <br />Send to: SAN JOAQUIN LOCAL HEALTH UISTIUCI' <br />1601 E. Haze l Lo n , P.O. Box 2009 <br />SLockton, CA 95201 466-67b1 <br />,;T 40 10/ 86 <br />