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INVENTORY RECONCILIATION <br />QUARTERLY SUMMARY REPORT FORM <br />FaciLity Name: <br />Facility;Address: <br />fAly R 1A t o C" CL- 0 00 X 53 3 <br />Telephone: 2_ 7 <br />Person Fili <br />Report - <br />Tank i Sizes. <br />Product <br />f C? .000 <br />l p <;. <br />02 ' U ov o <br />1 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 />0 Inventory variations exceeded the allowable limits for this quarter. t <br />hereby certify under penalty of perjury that the source for the variation <br />was not due to as unauthorized (leak) release. (Yes in Column 13 of the <br />Inventory Reconciliation Sheet) <br />List date, tank If, and amount for all variations that exceeded the <br />allowable limits. <br />Date Tank f /Amount <br />1. <br />2. <br />3. <br />4. <br />5. <br />AddiCional dates/amounts shall be continued on a separate sheet of <br />paper and attached. <br />If the source of the variation which.erceeded allowable limits was due to <br />A leak the incident shall be reported to S.J.L.H.D. Environmental Ilea Ith <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 I - January --) March <br />Quarter 2 - April --> June <br />Quarter 3 - July --> September , <br />Quarter 4 - October --) 04cember <br />Send to: SAN JOAQU I N LOCAL HEALTH DISTRICT <br />160L E. Hazelton. P.O. Bom 2009 <br />Stockton. CA 95201 466-6761 <br />Uc;T 40 10/86 • • <br />