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4 INVENTORY RECONCILIATION • <br />RTERLY SUMMARY REPORT FORM <br />• Facility Name: ` ^ <br />Facility Address: .q �� P� •n^ ,(J�1J <br />Telephone: a , <br />Person Filing <br />Report <br />eI 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. (Ho in Column 13 of the Inventory Reconciliation Sheet) <br />QI°vencory variations exceeded the allowable Limits for this quarter..•I <br />hereby certify under penalty of perjury that the source for the va_i <br />was not due to an uasu[horracioa <br />ized (leak) release. (Yes in Column of <br />Inventory Reconciliation Sheet) _ the <br />List date, tack i, eded the and amount for all variacioas that exce <br />alLovable limits. <br />Date Trak <br />—�- Amount <br />2. <br />3. <br />----- <br />5. r <br />Additional d4tcats shall be continued oo s separate sheet of <br />P Per and attatrachedhed.. <br />If the source of the <br />leak the incident variation which exceeded aL'lowable Limits was due to <br />= shall be reported to <br />authorized celesse•repoet�submitted <br />within 24 hours and as uronmental RCzlth <br />The quarterly summary report shall be submitted within 15 days of the end of each <br />quarter. <br />Quarter 1 January --> !larch <br />Quarter 2 — April —> June <br />Quarter 3 – July —> Septcmb,er <br />Quarter 4 October —> December <br />Send to: SAN JOAQUIN LOCAL HEALTH DISTRICT. <br />1601 E. Hazelton P.O. Box 2009 <br />1CT 40 I0/86 Stockton, CA 95201 466-6781 <br />