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INVENTORY RECONCILIATION <br />QUARTERLY SUMMARY REPORT FORM <br />Facility Address: 'j CL do(i��/ <br />C <br />Telephone: �-a-' N <br />Person Fil' g <br />Report <br />P� <br />hereby certify under penalty of perjury that all inventory variations for <br />ihe <br />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 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 />List date, tank f, and amount for all variations that exceeded the <br />allowable limits. <br />Date Tank I Amount <br />1. <br />2. <br />3. <br />4. <br />5 <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 Lica l th <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 cacti <br />quarter. <br />Quarter 1 - January --> March <br />art 2 - April --> June <br />rter 3 - July --> Septemher lc <br />anter - Octaber --> becelmber <br />Send to: SAN JOAQUIN LOCAL HEALTH DISTRICT <br />1601 E:. Hazelton, I' .0 . Box 2009 <br />Stockton, CA 95201. 466-6781 <br />UGT 40 10/86 <br />