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INVENTORY RECONCILIATION <br />QUARTERLY SUMMARY REPORT FORM <br />N <br />Facility Hame: <br />Facility Address: <br />Telephone :�A07— <br />Per ing <br />Re o opt <br />n <br />lEa . �r�•r-aSrn.s•.,I <br />APR 171989 <br />EN`JiRC)N •/;ENTAL HEALTH <br />PFDRAIT/QCrn nnr e, <br />LWA .�.;. <br />0---r 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 />QInventory 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 as unauthorized (leak) release. (Yes in Colu=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 />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 Health <br />within 24 hours and an unauthorized release report submitted. <br />The quarterly su— ary report shall be Submitted within 15 days of the end of each <br />quarter. <br />Quartr 1 - January --� Harch <br />Quarter 2 - April --> June <br />Quarter 3 - July --> September <br />Quarter 4 - October December <br />Send to: SAN JOAQUIN LOCAL HEALTH DISTIICT <br />1601 E. Hazelton, P.O. Box 2009 <br />Stockton, CA 95201 466-6781 <br />UCT 40 10/86 <br />