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I <br />1 ONVENTORY RECONCILIATION <br />IQUARTERLY SUMMARY REPORT FORM <br />Facility Name: <br />Facility Address: <br />Telephone: / <br />Person F1111. <br />Report <br />QI hereby certify under penalty of perjury that 811 inventory variations for <br />the above mentioned facility were within the allowable limits for this <br />quarter. (No in Column 13 of the Inventocy Reconciliation Sheet) <br />PW <br />Iaventocy variations exceeded the allowable Limits for this quarter. I <br />hereby certify under penalty of perjury that the source for the variation <br />was rant due to an unauthorized (leak) celeise. (Yes in Column 13 of the <br />Inventory Reconciliation Sheet) <br />List date, tank 1, and amount for all variat>� s 1>�at ,eed d e <br />allowable limits. <br />Date Tank f Amount OCT 24 1991 <br />2. 7tj J/7 <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 Che incident shall be reported to S , J . L. H. D. Environmental Ueslch <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 />QuA rter i - January --> March <br />Quarter 2 - April June <br />Quarter 3 - July --> September <br />Quarter 4 - October --> December <br />Send to: SAN JOAQUIN LOCAL HEALTH UIS'CKICT <br />1601 E. tare I t tan . P.O. Rom 2009 <br />SLockton. CA 95201 466-67bl <br />UD;T 40 10/86 <br />