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A <br />OYENTORY RECONCILIATION • <br />QUARTERLY SUMMARY REPORT FORM <br />Facility Name: zo <br />Facility Address: <br />Telephone: <br />Person Fi ng <br />Report <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. (Ho in Column 13 of the Inventory Reconciliation Sheet) <br />QInventory 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) release. (Yes in Column 13 of the <br />Inventory Reconciliation Sheet) <br />List date, tank /, and amount for all variations Chat exceeded the <br />allowable limits. <br />Date Tank f Amount <br />2. <br />3. <br />4. <br />5. <br />Additional dues/amounts shall be continued on a separate sheet of <br />paper and aCtached. <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 . N . 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:.rcer I - January --) March <br />Qlartcr 2 - April --> June <br />Quarter 3 - July --> Sepcember <br />Quarter 4 - October --) December <br />Send to: SAN JOAQU IN LOCAL. HEALTH DISTRICT <br />1601 E:. Hazel l on . P.O. Box 2009 <br />Stockton, CA 95201 466-67bl <br />lil;T 1.0 10/80 <br />