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3 � <br />INVENTORY RECONCILIATION ;�? <br />QUARTERLY SUMMARY REPORT FORM <br />facility Address: QC� Q0 IJ �/o S i <br />LJir rr 1' 3 <br />Telephone: <br />Person,Viling <br />Rep s s i <br />iCA <br />I 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 />INA 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 the <br />Inventory Reconciliation Sheet) <br />Listdate,- tank #f and amount for all variations that exceeded the <br />allowable limits. <br />Date Tank # <br />it <br />3. <br />.Amount <br />® _ <br />4. <br />I LC) <br />. • <br />Additional dates/amounts 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 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 <br />Quarter 3 - July --> September <br />Quarter 4 - October --> December <br />Send to: SAN JOAQUIN LOCA1, HEALTH DISTRICT <br />1601 H. Hazelton, P.O. Box 2009 <br />Seockton, CA 95201. 466-6781 <br />UGT 40 10/86 <br />