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y�o2Z 4,1 <br />INVENTORY RECONCILIATION <br />QUARTERLY SUMMARY REPORT FORM <br />Facility Name: ' <br />Facitity;Address: <br />-' t--- <br />Telephone: (,g,, -)G q c <br />Person F_i4� g <br />Report 6Za <br />{ <br />0 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 />Inveatocy 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 unauthorised (leak) release. (Yes in Column 13 of the <br />Inventory Reconciliation Sheet) <br />List date, tank 1, and amount for all variations that exceeded the <br />allowable Limits. <br />Date <br />2- l r- �.�- J,) <br />4. <br />s- <br />Tank f Amount <br />t) Ll <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 Rubmitted within IS days of the end of each <br />Quarter. <br />Quarter I - January --1 March <br />Quarter 2 - April --> June <br />Quarter 3 - July --> Septembor <br />Quarter 4 - October --> Occrmher <br />Send to: SAN JOAQU I N LOCAL HEALTH D 1 STK 1C'1'ENVIRCf�E`vYAL HEALTH <br />160L E. laza 1 t on , P.O. Box '200`) <br />F ERIJ111"/SERVICES <br />Sc ton, CA 45201 466-6761 • <br />1' 40 10/86 <br />