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41E NTORY RECONCILIATION <br />QUARTERLY SUMMARY REPORT FORM <br />raciLity Names <br />facility Addresss <br />Telephone: 361k, 395 5— <br />Person Filing <br />Reportc���« <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) releise. (Yes in Column 13 of the <br />Inventory Reconciliation Sheet) <br />List dates tank i, and amount for all variations that exceeded the <br />allowablt limits. <br />Date Tank f Amount <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 15 days of the end of each <br />quarter. <br />Quarter I - January --> March <br />Quarter 2 - April --> June <br />Quarter 3 - July --> September <br />Quarter 4 - October --> 04--cember <br />Send to: SAN JOA UIN LOCAL HEAL1'li D1STkIC't' <br />160L K. liaze1<oll P.O. BOX' ;A 4' <br />Stockton, ('A 95201 466-678 <br />UCT 40 10/86 <br />gn,TAt HEALTH s <br />ENVIRC • � <br />2 <br />,5e � F ERtJ►tl" /SERVICES 1 <br />