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INVENTORY RECONCILIATION <br /> QUARTERLY SUMMARY REPORT FORM <br /> Facility Name: Q U,►K S- A '*125 Tank t <br /> Size Pcoduct <br /> PAC. ity Address: /5 � J, YAs�l �r, o �Op EG <br /> a G <br /> Telephone : Zoy- 599- 2.25/ <br /> Person Filing <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. (No in Column 13of 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, tack t, and amount for all variations that exceeded the <br /> allowable limits. <br /> Date rank t Amount <br /> 1 . <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 liealth <br /> within 24 hours and an unauthorized release report submitted. <br /> The quarterly summary report shall be submitted within 15 days the - DoE each <br /> quarter . c <br /> Jarcer I - January --> March rn <br /> c - <br /> April --> June rd�p ' <br /> Quarter 7 - July --> September t <br /> Qlaarter 4 - October --> December <br /> .0000 <br /> Send to: SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. Hazelton , P .O . Box 2009 <br /> Stockton , CA 95201 466-6781 <br /> LILT 40 10/86 <br />