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A <br />NVENTORY RECONCILIATIONTER Y L SUMMARY REPORT FORM <br />Facility Name: -Y, ti 'n <br />Facility Address: �� Q� ! • n ^ ,,(h1J Telephone: <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 />QInventory variations exceeded the allowable Limits for this quarter.. I <br />hereby certify wader Per of perjury that the source for the var_iacion <br />U23 cot due to an unauthorized (leak) release. (Yes in Column 13 of the <br />Inventory Reconciliation Sheet) —' <br />List date, tank 1, and amount for all variscioos that <br />allowable limits. exceeded the <br />Date Tank I . <br />--- Amount <br />2_ <br />4. - <br />5. <br />Additional ats shall be continued on a separate sheet of <br />ou <br />Paper and attachettached.. <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. E-=vires�eatai a to <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 I January —> March <br />Quarter 2 -- April —> June <br />Quarter 3 _ July —> September r �� <br />br s <br />Quarter 4 - October —� <br />December <br />Send to: SAN JOAQUIN LOCAL HEALTH DISTRICT <br />1601 E. Hazelton, P.O. Box 2009 <br />ICT 40 IO/86 Stockton. CA 95201 466-6781 <br />