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0 0 <br />INVENTORY RECONCILIATION <br />QUARTERLY SUMMARY REPORT FORM <br />Facility Name: - 4XCO i' i <br />Facility Address: t a j' <br />r ' 1 <br />Person Filing`,' <br />Report :04 <br />.. <br />hereby certify underpenaltyof perjury <br />the . •. mentioned <br />.••rd <br />quarter. (No 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 an unauthorized (leak) release. (Yes in Column 13 of'theInventory Reconciliation Sheet) <br />List date, tank f, and amount for all variations that exceeded the <br />allowable limits. <br />'i <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 Uealth <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 />Quarter 2 April ---> June l ®/ <br />Quarter 3 - July --> September It <br />Quarter 4 - October --> December <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 />... � , • .. r.. • .•i _ �:wwa> . •sti•:- •--.,.r•i •jt.tC.T'i } J.i�r ir.•C <br />3.•• _ dee s :�.?.•'. " .. � � � ...... _ .. .. <br />