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INVENTORY RECONCILIATION <br />QUARTERLY SUMMARY REPORT FORM <br />raCLL1ty Name: . <br />es <br />s <br />Fac. ity Address: <br />1; %3* <br />Telephone: LVIOAF — <br />Person FiIL <br />Repo <br />1 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 13of the Inventory Reconciliation Sheet) <br />V'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) release. (Yes in Column 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 # A=unt <br />z. <br />3. <br />4. <br />S. <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 />wit I hin 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 />qUArccr. <br />Quarter I January March <br />QUarter 2 April June <br />Quarter 3 July September <br />QA-iarter 4 October December <br /><amend to: SAN JOAQUIN LOCAL HEALTH DISTRICT <br />1601 E. Hazelton, P.O. Box 2009 <br />UGT 40 10/86 Stockton, CA 95201 466-6781 <br />