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G <br />INVENTORY RECONCILIATION <br />QUARTERLY SUMMARY REPORT FORM <br />Facility Name: M z .mss <br />Facility Address: <br />Telephone: l2bg) 594-3-115 <br />Person Fi(1\ ingp <br />Report \c>cu\ �'Yl�c�seti <br />ize <br />ElI 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 #, mad amount for 211 variations that exceeded the <br />allowable limits. <br />Date Tank I Amount <br />I. -1-3 l a 9- 343 30� <br />2. "1-4 Irl 294.9C1 <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 allowable limits was due to <br />a leak the incident shall be reported to S .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 --) December <br />Send to: SAN JOAQUIN LOCAL HEALTH DISTRICT <br />1601 E. 11azelLon , P.O- Box 2009 <br />Stockton, CA 95201 466-6781 <br />UCT 40 10/86 <br />