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INVENTORY RECONCILIATION <br />QUARTERLY SUMMARY REPORT FORM <br />Facility Name:, <br />® \\yy <br />.Facili.ty','Address: 0- <br />9 <br />k: k <br />Telephone <br />Person <br />'.i <br />■ 1 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 Colu='l 13of the Inventory Reconciliation Sheet) <br />ElInventory variations exceeded the allowable limits fortis quarter. I <br />hereby certify under penalty of perjury that the source for the variation <br />was not due to an unauthorized (leak) leise- (Yes in Column 13 of the <br />Inventory Reconciliation Sheet) <br />List date. Cank #t and &mount 1all variationsthatexceeded the <br />allowable <br />Amount 4 <br />tt S <br />0,v > 01999 <br />17, <br />Additional dates/amouats shall be continued on a separate sheet of <br />paper 3,nd attached. <br />If the source of the variation which. exceeded al-lowabte limits was due to <br />a leak the incident shall be reported to S,J.L. .D. Environmental Health <br />Within 24 hours and an unauthorized release report submitted. <br />The quarterly summary report shall be submitted within OS days of the end of each <br />quarter. <br />d <br />Quarter 6 - .January --> March <br />Quarter 2 - April --) June <br />Quarter 3 - July --> Sep>tember <br />Quarter 4 - October --> December <br />Send to; SAN JOAQUIN LOCAL HEALTH DISTRICT <br />1601 E. Haze l Lo n , P.O. BOX 2009 <br />Stockton. CA 95201 Aft -_ <br />EH 23 019 10/86 <br />Date <br />Tank <br />1. <br />t- Qk® l� <br />2. <br />3. <br />4. <br />1 t 1, ` °l <br />t <br />Amount 4 <br />tt S <br />0,v > 01999 <br />17, <br />Additional dates/amouats shall be continued on a separate sheet of <br />paper 3,nd attached. <br />If the source of the variation which. exceeded al-lowabte limits was due to <br />a leak the incident shall be reported to S,J.L. .D. Environmental Health <br />Within 24 hours and an unauthorized release report submitted. <br />The quarterly summary report shall be submitted within OS days of the end of each <br />quarter. <br />d <br />Quarter 6 - .January --> March <br />Quarter 2 - April --) June <br />Quarter 3 - July --> Sep>tember <br />Quarter 4 - October --> December <br />Send to; SAN JOAQUIN LOCAL HEALTH DISTRICT <br />1601 E. Haze l Lo n , P.O. BOX 2009 <br />Stockton. CA 95201 Aft -_ <br />EH 23 019 10/86 <br />