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• <br />INVENTORY RECONCILIATION <br />QUARTERLY SUMMARY REPORT FORM <br />Facility Name: <br />Facility Address: 657-7) MO 1VO&IWA <br />%Kn numM1, . C-#! G,'�35 <br />Telephone - <br />Person Film <br />Report --- �--�� I -4 <br />i <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 />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 Column13 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 f Amount <br />1. <br />2. <br />3. <br />4. <br />S. <br />Additional dateslamounts 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 submitted within 15 days of the end of each <br />quarter. <br />Fa <br />e - January --� March <br />-April --> Junerter 3 - July --> September <br />Quarter 4 - October --> December <br />Send to: SAN JOAQUIN LOCAL HEALTH DISTRICT <br />160L E . llazelton , 1' .0 . Box 2009 <br />Stockton, CA 95201- 466-6781 <br />UGT 40 10 / 8©C1C' SMA\� �•�S �SJ MPY <br />