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INVENTORY RECONCILIATION <br />QUARTERLY SUMMARY REPORT FORM <br />Facility � <br />i � I // ♦ '` <br />•„ / <br />Te •, _ r L_ <br />Person <br />Report <br />L 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 />Inventory variations exceeded the allowable limits for tbis quarter. t <br />hereby certify under penalty.of perjury that the source for the variation <br />was not due to an unauthorised (leak) release. (Vas is Column 13 of the <br />Inventory Reconciliation Sheet) <br />List date, tack i® and amount for all variations that exceeded the <br />allowable limits. <br />Date Tank Amount <br />1. <br />2. <br />3. <br />4. <br />S. <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 unauthorised release report submitted. <br />ncC quarterly summary report shall be submitted within 15 days of the end of each <br />quarter. <br />Quarter I - January --' March 11901 <br />Q,arter 2 - April --> June `! l <br />Quarter 3 July --> September ®/ <br />Quarter 4 October --> t)ecember <br />Send to: SAN JOAQUIN LOCAL HEALTH U15'rKICT <br />1601 E. flaze 1 t on . P.O. Rox 2009 <br />Stockton. CA 95201 466-67bl <br />GT 40 10/86 <br />