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INYENTORY RECONCILIATION <br />QUARTERLY SUMMARY RFPORT FORM <br />Facility Name: a& GI IZV UG- PARK <br />Facility Address: <br />Telephone: <br />Person Filing <br />Report — <br />Tank I Sizc ProducC <br />© 1 hereby certify under penalty, of perjury that all inventory variations for <br />Che above ncnCioned facility -ere within the allowable limits for Chis <br />Quarter. (No in Colum 13of the laveatory Reconciliation Sheet) <br />C1IavenCory 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 Co ■o unauchori=ed (leak) release. (Yes in Column 13 of the <br />InveacorY Reconciliation Sheec) <br />List date., -cask 1. and amount for all variations Chat exceeded the <br />allowable Liaics_ <br />-Date �',''. Tank / Amount <br />1. <br />3. <br />4. <br />AddzCzonal dates/amouats chill be conCzaued on a separa Ce sheet of <br />paper.and attached. <br />if the source of Che variation which c<cccdcd Sllo-able Limits was duc Co <br />• leak the incident shall be reported Co S.J.L.H.D. Environmcncal Ilcalch <br />w LChln 24 hours and an unauChorized release report submicced. <br />The Quarterly sunmary rcporc shall be submitCcd within IS days of the end of each <br />qu"Icr. <br />QwarLr-r I - Januwry --) Mirth <br />Qiartcr 2 - April <br />Quarc.•r ) - J.ly __) Jc p[cmh.•r <br />Ql.artcr 4 - OCCabcr --) IkrCcmbcr <br />Send Co: SAN JOAQIIIry LOCAL HEALTH DISTIcICI <br />1 60 1 1' . ]!.-I 7.0 I 1 4n1 • P . 0 14u.e 2,009 <br />SCockcon. CA '15201 466-67b1 <br />'.0 10/N6 <br />