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r , 9 INVENTORY RECONCILIATIA <br />"V QUARTERLY SUMMARY REPORT FORM <br />Facility Name: n r <br />Facility Address:3 <br />Telephone: A <br />Person Filing <br />Report:. <br />f M oVF-G-t- <br />f�-- <br />k-k-� 7, 11 <br />Tank # Size Product <br />I hereby certify under penalty of perjury that -all inventory variation; <br />for the above mentioned facility were within the allowable limits for <br />this quarter. (No in Column 13 of the Inventory Reconciliation Sheet.: <br />Inventory variations exceeded the allowable limits for this quarter. <br />hereby certify under penalty of perjury that the source for the varia- <br />tion was not due to unauthorized (leak) release. (Yes in Column 13 of <br />the Inventory Reconciliation Sheet). <br />List date, tank #, and amount for all variations that exceeded <br />the allowable limits. <br />Date <br />Tank # <br />Amount <br />1. <br />2. <br />3. <br />4. <br />5. <br />Additional dates/amounts shall be continued on a separate sheet <br />paper and attached. <br />If the source of the variation which exceeded allowable limits was <br />due to a leak, the incident shall be reported to San Joaquin Local <br />Health District; Environmental health Division, within twenty-four <br />(24) hours and an unauthorized release report submitted. <br />The quarterly summary report shall be.submitted within fifteen (15) days <br />of the end of each quarter. <br />Quarter 1 - January --- ------- >March <br />Quarter 2 - April ------------ >June <br />Quarter 3 - July ----- =------- >September <br />Quarter 4 - October ---------- >December <br />01 <br />Send <br />cj <br />Send to: SAN JOAQUIN LOCAL HEALTH'DISTRICT <br />1601 E. Hazelton, P.O. Box 2009 <br />Stockton, CA 95201 468-3420 <br />LII 23 019 10/86 <br />