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INVENTORY RECONCILIATION <br />QUARTERLY SUMMARY REPORT FORM <br />Facility Name: Tank_I Size <br />0 I hereby certify under penalty of perjury that all imentory 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) releise. (Yes 3n Column 13 of the <br />Inventory Reconciliation Sheet) <br />List date, tank 1, and amount for all variations that exceeded the <br />allowable limits. <br />Date Tank f Amount <br />1. <br />2. <br />3. <br />4. <br />5. <br />uc <br />P'N Wm <br />J A N 2 3 1992 <br />ENVIRMAENTAL HEALTH: <br />PEWWT/SE RVIC.S <br />Additional dates/amounts shall be continued on a separate sheet of <br />paper snd attached. <br />If the source of the variation which.exceeded al -lovable limits was due to <br />a leak the incident shall be reported to S.J.L.H.D. Environmental liealch <br />within 24 hours and an unauthorized release report submitted. <br />The quarterly summary report shall be submitted within 13 days of the end of each <br />Quarter. <br />Qu:.ctcr I - January --> March <br />Qiartcr 2 - April --> June <br />Quarter 3 - July --> Septcmh4:r <br />Quarter 4 - October --> Ikkcember <br />Send co: SAN JOAQUIN LOCAL HEALTH UIS'l'HICT <br />160L E. I aze 1 t (in . P.O. Box 2009 <br />SLockcon. CA 95201 466-67b1 <br />LILT 40 10/86 <br />