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0 0 <br />INVENTORY RECONCILIATION <br />QUARTERLY SUMMARY REPORT FORM <br />Facility Name: <br />11' L r <br />Facility Address: <br />I` <br />w <br />Person <br />V <br />perjury& I hereby certify under Penalty of <br />the above mentioned facility were within the allowable limits for this <br />• in Column 13of the Inventory Reconciliation Sheet) <br />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 so unauthorized (leak) release. (Yes in Col <br />umn Inventory Reconciliation Sheet) 13 of the <br />List date, tank #® and amount for all variations that exceeded the <br />allowable Limits. <br />Date Tank # Amount <br />2. <br />3. <br />4. <br />5. <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 I January --> March <br />Quarter 2 - April --> June <br />Quarter 3 WJuly --> September <br />Quarter 4 - October --> December C <br />Send to: SAN JOAQUIN LOCAL HEALTH DISTRICT <br />1601 E. Hazelton, P.O. Box 2009 <br />11CT 40 I0/86 Stockton, CA 95201 466-6781 <br />aft ri` 77' ..:rsr+wa� ...�e•. .Li• <br />