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l <br />• <br />INVENTORY RECONCILIATION <br />QUARTERLY SUMMARY REPORT FORM <br />Fac i Lite Name: C11 <br />Facility Address:_ 3q <br />1D,0; , <br />Telephone 14 31,u-i,175- <br />Person <br />1,u. ,I75Person Filing <br />Report Rle-j4 ��n"ve moo. <br />ni HEALTH <br />�EryV' ""Q <br />Tank i <br />Size <br />Product <br />`3 <br />4 <br />Ike L <br />Z, <br />2 e <br />I hereby certify under penalty of perjury that all inventory variations for <br />T 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) releise. (Yes in Column 13 of the <br />Inventory Reconciliation Sheet) <br />List date, tank i, and amount for all variations that exceeded the <br />allowable limits. <br />Date Tank E 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 IS days of the end of each <br />quarter. <br />Quarter 1 - January --� March <br />cel a r 1 eT-3 <br />Quarter 3 - July --> September <br />Quarter 4 - October --> Ikccmber <br />Send to: SAN JOAQUIN LOCAL HEALTH DISTRICT <br />160L E. Haze 1 <<►n , P.O. Box 2009 <br />Stockton, (:A 95201 466-6781 <br />UGT 40 10/86 <br />