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INVENTORY RECONCILIATION APR 1 1111 <br /> QUARTERLY SUMMARY REPORT FORM -NVw I NT L H AL1 � <br /> PFRMIT/SERVICE. <br /> Facility Name: Tank I Size Product <br /> Facility Address: � .?/ /�� W <br /> Telephone : <br /> Person Filing <br /> Reporu 74.1 <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 l3 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 /> was not due to an unauthorized (leak) releise. (Yes in Colum 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 alA owabie limits was due to <br /> a leak the incident shall be reported to S .J L }I D Environmental health <br /> wiLthin 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 1 - January --) march <br /> Q'13rter 2 - April --> Jure <br /> Quarter 3 - Jelly --> September <br /> Q+,artcr 4 - October --) 04-cember <br /> S'tnd to= SAN JOAQUIN 1,0GA1, HEALTH UISTkICT <br /> 160 1 E , Haze 1 t (51) , 1' . 0 . 15ox 1!1013 <br /> St. ockLon , CA 95201 466 -6781 <br /> t)(;T 1+0 10/ 86 <br />