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INVENTORY RECONCILIATION <br /> QUARTERLY SUMMARY REPORT FORM <br /> Facility Name: (�(AAk, S-MA #025 MS <br /> ize Product <br /> PAC. ity Address: 5'� 00d/ CJI Aim � <br /> I PQAJ OA 94,16/- <br /> -Telephone : <br /> 4,166,Telephone : <br /> Person Filing <br /> Report ` <br /> I hereby certify under penalty of perjury <br /> that all inventory <br /> the above mentioned facility were within the allowable lim tsvforathis$for <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, tank #, 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 sumanary report shall be submitted within 15 days of <br /> quarter . the end of each <br /> Quarter I - January --) March <br /> Quarter 2 - April --> June f 9 <br /> tec 3 - July --> Set tember t <br /> ,artcc 4 - October --> December <br /> ..end to: SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. Hazelton , P .O . Box 2009 <br /> UCT 40 10/86 Stockton , CA 95201 466-6781 <br />