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INVENTORY RECONCILIATION <br />QUARTERLY SUMMARY REPORT FORM <br />Facility Name: 6L"�' S <br />Facility Address: MIM 114±e <br />L --t a n G Psi <br />Telephone: e4,1,9- -1144 <br />Person Filing <br />Report <br />1 .1 <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 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) release. (Yes in Colt= 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 # Amount <br />1. <br />2. <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 />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 />Quarter I January March <br />art April June <br />rtes 3 July September ZI <br />Quarter 4 October December <br />Send to: SAN JOAQUIN LOCAL HEALTH DISTRICT AUG 101988 <br />1601 E. Hazelton, P.O. Box 2009 <br />Stockton, CA 95201 466-6781 ENVIROMENT AL HEALTH <br />LICT 40 10/86 IT/ VICE <br />