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• <br />INVENTORY RECONCILIATION <br />QUARTERLY SUMMARY REPORT FORM <br />Facility. Names <br />FAcility ,Address: d 4y dI <br />Telephone: <br />Person Filing.� <br />Report _ cJla14/ /0 <br />• <br />Tank I -rt —Ze Product <br />�Ob - <br />�, <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 />0 Inventory variations exceeded the allowable limits for this quarter. I <br />hereby certify under penalty of perjury that the source for the variation <br />vas not due to an unauthorized (leak) release. (Yes in Coltman 13 of the <br />Inventory Reconciliation Sheet) _ <br />List date, tank It 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 />e r <br />JU <br />tNV�RO � 3 <br />Nfi EN <br />PERT/SER TAL HEALTH <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 Hcalth <br />Within 74 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 />- Jaouary <br />--> March <br />Quarter 2 <br />- April <br />June <br />Quarter 3 <br />- July <br />--> September <br />Quarter 4 <br />- October <br />--> [k cr-mber <br />Send to: SAN JOAQUIN LOCAL HEALTH DISTRICT <br />1601 L. Ilaze l t <►n , l' . 0 . ROx 2009 <br />U(; Z' 40 10/86 SLockt:on, CA 95201 466-6781 <br />