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*VENTORY RECONCILIATION <br />QUARTERLY SUMMARY REPORT FORM <br />• <br />RECEIVED <br />J U L 2 5 1991 <br />ENVIRONMENTAL HEALTH <br />Facility Name: <br />Facility Addre <br />Telephone: Q <br />Person F in <br />Report <br />0 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 />ElInventory 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 in 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 />S. <br />AAditional dates/amouots shall be continued on a separate sheet of <br />paper and attached. <br />Lf 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 />wiChin 24 hours and an unauthorized release report submitted. <br />The quarterly summary report shall be submitted within 15 days of the and of each <br />quarter_ <br />Qu:rtcr I - January --> March <br />Quarter 2 - April June <br />Quarter 3 - July --> September <br />Quarter 4 - October --> tk comber <br />Send co: SAN JOAQUIN LOCAL HEALTH DISTRICT <br />1601 E. Hazelton. 1' .0 . lice 2009 <br />SLockcon. CA 95201 466-67b1 <br />Uc;T 40 10/86 <br />