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I <br /> INVENTORY RECONCILIATION �,V1R0 ' , fi4 <br /> QUARTERLY SUMMARY REPORT FORM PERfi�t1�1J� V,C � <br /> Facility 'Name: <br /> t C s✓ ' Tank f Size Product <br /> Telephone : C� <br /> Person Filing <br /> Report /l//` ZiZ <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 sa unauthorized (leak) releise. (Yes in Column 13 of the <br /> Inventory Reconciliation Sheet) <br /> List date, tank 1, 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 /> S. <br /> Additional dates/amounts shall be continued on a separate sheet of <br /> paper and attactied. <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 IS days of the end of each <br /> quarter. <br /> Quarter I - January --) Harch <br /> Quarter 2 - April --> Juni <br /> Quarter 3 - Juiy --) September <br /> Q,jarter 4 - October --) t?ccc-mbEr <br /> Send to: SAID JOAQUIN IMCAL HEALTH DISTkICT <br /> I6() 1 1: . k';zzt' l t win , 1' . U . hox 2009 <br /> St. ockt-on , CA 95201 466 -67b1 <br /> 1fc;T 40 10/ 86 <br />