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INVENTORY RECONCILIATION <br /> QUARTERLY SUMMARY REPORT FORM <br /> Facility Name: ( S ry� 7r/2K WIS <br /> �F----- - Product <br /> Fac- ity Address;Telephone : <br /> Person Filing <br /> Report <br /> 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 /> ElInventory variations exceeded the allowable Limits for this quarter_ I <br /> hereby certify under penalty of perjury that the source for the variation <br /> vas not due to an unauthorized (leak) release. (Yes in Column 13 of the <br /> Inventory Reconciliation Sheet) <br /> Lis[ date, tank #, and amount for all variations that exceeded the <br /> allowable limits. <br /> Date Tank # 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 <br /> within 24 hours and an unauthorized S .J .L. ti. D. Environmental Health <br /> release report submitted. <br /> The quarterly summary report shall be submitted Within <br /> quarter , IS days of the end of each <br /> Quarter I - January --> March <br /> Quarter 2 - April --> June <br /> Quarter 3 - .July --> September <br /> Q";rte� - October --> December 1990 1 lq <br /> 0 <br /> amend 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 />