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INVENTORY RECONCILIATION <br />JUARTERLY <br />SUMMARY REPORT FI: r <br />Facility Name: -� S-- <br />FsciliCy Wdresss ` <br />Telephone:2 . <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 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 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 f Amount <br />1. <br />2. <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 at-lowable 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 <br />- January <br />--> <br />March <br />Quarter 2 <br />- April <br />--> <br />June <br />Quarter 3 <br />- July <br />--> <br />September <br />Quarter 4 <br />- October <br />--> <br />lkcember <br />Send to: SAN JOAQUIN LOCAL HEALTH DISTRICT <br />1601 E. Haze 1 call , P.O. Box 1000 <br />SCockton, CA 95201 466-6781 <br />LIM; 40 10/86 <br />