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4 • , <br />INVENTORY RECONCILIATION <br />QUARTERLY SUMMARY REPORT FORM <br />Facility <br />facility <br />Telephs <br />Person <br />Report <br />I hereby certify un4er penalty of perjury that all inventory variations for <br />the above mentioned facility were within the allowable limits for this <br />quarter. (� in Colum 13 of the Inventory Recoaciliati0a 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 />s not due to an unauthorised (leak) release.. (yes in Column 13 of the <br />ZUW!MtGCY 9144004iligtiOls Sheet) . <br />List date, tank #p and amount for all variations that exceeded the <br />allowable* limits. <br />Date Tank Amount <br />3. <br />ditional dates/ uots shall be continued on a separate sheet of <br />paper and attached. . <br />a <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 />The quarterly summary report shalt be submitted within 15 days of the end of each <br />- qusrter. , <br />ctec 1 - January -4 March ' <br />Quarter 2 - April - --? June <br />Quarter 3 - July --' September <br />Quarter 4 - October --> December <br />Send to: SAN JOA ;N LOCAJ. HEALTH DIST"CT <br />1601 E. Hoz6'1ton",'-", '.0. Box 2009 <br />• Scockton, CA 95201 466-6781 <br />` UGT 40 10/86 <br />