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INVENTORY RECONCILIATION <br />QUARTERLY SUMMARY REPORT FORM <br />Facility Name: 11AA11# <br />Facility Address: /�',//) <br />PersoniReport'a % <br />i <br />WAJ�!////,/IN, <br />WITTWOMA <br />L 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 />_ w <br />E] Inventory variations exceeded the allovable 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) release. (Yes in Coluam 13 of the <br />Inventory Reconciliation Sheet) <br />List date, tank f, 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 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 the incident shall be reported to S.J.L.H.D. Environmental Health <br />within 24 hours and an unauthorized release report submitted. <br />The quarterly sumaaary report shall be submitted within 15 days of the end of each <br />quarter. <br />QuArter I - January --> March <br />Quarter 2 - April --> Jude <br />xQuarter 3 - July --> September <br />Quarter 4 - October --> tkcember <br />Send to: SAN JOAQU IN 1.0CAL HEAL1'1i DISTRICT <br />1601 E. Haze I t oo . P.O. Box 2009 <br />Stockton. CA 95201 466-6781 <br />11t;1* 40 10/90 <br />