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INVENTORY RECONCILIATION <br />QUARTERLY SUMMARY REPORT FORM <br />Facility Name: �-�rod �� �j S ZX, ; <br />Facility Address:3,o ZVj <br />Telephone: b�- �6 /� �0 <br />Person Filing <br />Report <br />MAY g + 1989 <br />Tank Size Product <br />1 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 13of the Inventory Reconciliation Sheet) <br />E] 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 1, and amount for all variations that exceeded the <br />allowable limits. <br />Hate Tank I? 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 attached. <br />If the source of the variation whichexceeded allowable limits was due to <br />At 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 gubmitted within IS days of the end of cacti <br />quarter. <br />Quarter I - January --) H.irch <br />Quarter 2 - April --> June <br />Quarter 3 - July --> September <br />Quarter 4 - October --> lkccmber <br />Send to: SAN JOAQUIN LOCAL HEALTH DISTRICT <br />1601 1:. laza 1 I (in . I' . 0 . lice 200`) <br />SLockton. CA 95201 466-67bi <br />IGT 40 10/86 <br />