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e — e <br />P= INVENTORY RECONCILIATION <br />QUARTERLY SUMMARY REPORT FORM <br />Facility Name: oAAAU) 1-61311 <br />Facility Address:_ <br />Telephone: a? Q. <br />Person F in <br />Report <br />duct <br />® 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.CoLu=a 13 of the Inventory Reconciliation Sheet) <br />V. <br />0 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 in Column 13 of the <br />Inventory Reconciliation Sheet) <br />List date, tank t, and amount for all variations that exceeded the <br />allowable liaaits. <br />Date Tank f Amount <br />2. <br />3. <br />4. <br />S• <br />Additional dates/amounts shall be continued on a separate sheet of <br />paper snd attached. <br />If the source of the variation vhich.exceeded al-lowable limits was due to <br />a leak the incident shall be reported to S.J.L.H.D. Environmental liea•lth <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 I - January --> Harch <br />Q,iarter 2 - April --% June <br />Quarter 3 July --> September <br />N w <br />Quarter 4 - October --> December <br />Send to: SAN JOAQU IN LOCAL HEALTH DISTRICT <br />1601 E. Haze 1 t oil . P.O. Hoo 2009 <br />SLockton. CA 95201 466-6161 <br />LI ;T 40 10/86 <br />