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INVENTORY RECONCILIATION <br />QUARTERLY SUMMARY REPORT FORM <br />Facility Nas,e: - /�a Iyl VNO.H;yI ho" <br />raeility Address: /Sp a AJ / I-), ,d <br />Telephone: <br />Person Filing <br />Report <br />JUL "101983 <br />ra3D�Dl� <br />ea,,�I hereby certify under penalty of perjury that all inventory variations for <br />the above s utioned facility were within the allowable limits for this <br />Quarter. (No in Colu® 13of 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 as unauthorized (leak) releiee. (Yes in Column 13 of the <br />Inventory Reconciliation Sheet) <br />C <br />List date, tank f, ■od amount for all variations Chat exceeded the <br />allowable Limits - <br />Date Tank 0 Amount <br />1. <br />2- <br />3- <br />4. <br />5. <br />- <br />3_4- <br />5_ <br />Additional daces/aawunts shall be continued on a separate sheet of <br />Paper and aCcached, <br />[f 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 Ilcalch <br />Within 24 hours and an unauthorised release report submitted. <br />The Quarterly suamary re porC shall be submitted within 15 days of the end of each <br />Quar(r r. <br />Quartcr I - January --) march <br />u rter 2 - April --) Jone <br />Quarter ) - Jwly -_) Scp(emher <br />Quarter 4 - October --) Drcember <br />Send co: SAN JOAQUIN LOCAL HEALTH DISTRICT <br />1601 E. Haas l l inl, P.O. R(ix M19 <br />Stockton, CA 95201 466-67bl <br />lu:l' 40 10/86 <br />