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INVENTORY RECONCILIATION <br />QUARTERLY SUMMARY REPORT FORM <br />Facility Hame: 17,37A'01 <br />Facility -'Address: 38S /r1FSTCKrINTL//rit <br />TRAPY CA 95371 <br />Telephone: 201 - 835- 8920 <br />Person Filing <br />Report /1.1V, MILLIC,9W 'YG6Z <br />Tank f Size Product <br />19 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. (Ho in Colu® 13 of 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 an unauthorized (leak) releiae. (Yea in Column 13 of the <br />Inventory Reconciliation Sheec) <br />List date, tank /, and amount for all variations that exceeded the <br />allowable limits. <br />Date Tank IF Amount <br />2. <br />f <br />3. <br />4. <br />S. <br />Additional daces/s uerm shall be continued on a c�parate of <br />paper and attached. <br />[f the source of Che variation uhich. exceeded allowable limits w;8 due to <br />a leak the incident shall be reported to S.J.L.H.D. Envirar=ent:.l Health <br />within 24 hours and an unauthorircd release rcpare submitted. <br />The quarterly su —cy report shzll be submitted within 15 days of the end of each <br />quarter. <br />Quarter I - January --) March <br />Quarter 2 - April --> June <br />Quarter 7 - July —> September Q <br />Quarter 4 October --) December / / co l<✓ <br />Send co: SAN JOAQUIN LOCAL HEALTH DISTRICT <br />1601 E. Haze IL/ul, 1'.0. BOX 1009 <br />SLockcon. CA 95201 466-678L <br />T 40 10/86 <br />