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W1. 0 0 <br />1NYENTORY RECONCILIATION <br />QUARTERLY SUMMARY REPORT FORM <br />Facility Han�e: <br />Facility Address: <br />Telephon <br />PersonReporc V;��• / <br />Jp```�J <br />OCT 1 c 1989 <br />C] 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 />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) relcise. (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 />5. <br />Additional daces/amounts shall be continued on a separate sheet of <br />paper and attached. <br />If Che source of the variation which.exceeded allowable limits was due: to <br />a leak the incident shall be reported co 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 />Qu:.rter 1 - January --> March <br />Q+sarter 2 - April --> June <br />Quarter 3 - July --) Sepccmh.:r <br />Quartcc 4 - Occobcr --> D--cembcr <br />Send co: SAN JOAQU IN 1.0CAI_ HEALTH DISTRICT <br />160L h. Hazelton. P.O. lice 2009 <br />SLockcon, CA 95201 466-6781 <br />LILT 40 10/86 <br />