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4 INVENTORY RECONCILIATIO <br />QUARTERLY SUMMARY REPORT FORM <br />Facility Name: � , (� ot/5Z <br />n w <br />Address: <br />Person Fili <br />r <br />VI 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 />vas not due to an unauthorized (leak) release. (Yes in Col uma113 of the <br />Inventory Reconciliation Sheet) <br />List date, tank i, and amount for all variations that exceeded the <br />allowable limits. <br />2. <br />3. <br />4. <br />5. <br />Additional dates/amouats 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 />n e quarterly summary report shall be submitted within 15 days of the end of each <br />quarter. <br />Quarter 1 - January --) Harch <br />Quarter 2 - April --> June <br />Quarter 3 - July --> September <br />Quarter 4 - October --> December` F, <br />Send to: SAN JOAQUIN LOCAL HEALTH DISTRICT <br />1601 E. Hazelton, P.O. Box 2009 <br />Stockton_ CA 952n! LAA-t'7A1 <br />