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INVENTORY RECONCILIATION <br /> G 4 <br /> QUARTERLY SUMMARY REPORT FORM <br /> Facility Name: Q04 -/tPTank # Size <br /> Product <br /> - <br /> Fac. ity Address: ® � v D r <br /> JA 52 <br /> Telephone : 0(4 _t0-1 3 <br /> Person Fili--� <br /> Report <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 13of 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 #, and amount for all variations that exceeded the <br /> allowable limits. <br /> Date Tank # Amount <br /> 1. !0- z 1 f 3 <br /> 2. <br /> 3. to p 1 -f-/ � <br /> 5- !/- /4 <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 submitted within 15 days of the end of each <br /> quarter. <br /> Quarter 1 - January --) March <br /> Quarter 2 April --> June <br /> Quarter 3 - July --> September <br /> Quarter 4 - October --> December <br /> Send to: SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 F Hazelton , P .O . Box 2009 <br /> Stockton, CA 95201 466-6781 <br /> _LICT 40 10/86 <br />