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• <br />INVENTORY RECONCILIATION <br />QUARTERLY SUMMARY REPORT FORM <br />Facility Name: <br />Fac. ity Address: 1050 SO o tee. 14"ve <br />, S 7' ,'tn Cf- '75- � � <br />Telephone: yq 73� <br />Person Filing <br />L <br />JJ <br />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 Column 13 of the <br />Inventory Reconciliation Sheet) <br />List date, tank i, and amount for all variations that exceeded the <br />allowable limits. <br />Date <br />1. <br />2- <br />3. <br />4. <br />5. <br />Tank f Amount <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 />Send to: <br />IICT 40 10/86 <br />Quarter I <br />- Januar <br />--J March <br />garter 2 <br />- April-->leprmbcr <br />Quarter 3 <br />- July <br />-- <br />Quarter 4 <br />- October <br />--> December <br />SAN JOAQUIN LOCAL HEALTH DISTRICT <br />1601 E. Hazelton, P.O. Box 2009 <br />Stockton, CA 95201 466-6781 <br />