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Facility Name: <br />Facility Address: <br />Telephone: <br />Person Fil <br />Report <br />INVENTORY RECONCILIATION <br />QUARTERLY SUMMARY REPORT FORM <br />j c <br />�9 t 5eq r Tank <br />L E' <br />Product <br />a -.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 />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 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. <br />2. <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 summary report shall be submitted within 15 days of the end of each <br />- quarter. <br />Quarter I - January --> March <br />Quarter 2 - April --> June q : <br />Quarter 3 - July September '` �4Uq. <br />Quarter 4 - October --> December <br />Qu � <br />Send to: SAN JOAQUIN LOCAL HEALTH DISTRICT JAN` - <br />1601 E. Hazelton, P.O. Box 2009 ENVIROmENTAL HEALTH <br />Stockton., CA 95201 466-6781 EERMIT/SERVICES <br />UGT 40 10/86 <br />