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INVENTORY RECONCILIATIO <br /> QUARTERLY SUMMARY REPORT FORM <br /> Facility Name : SAN JQAQUIN BEVERAGE INC <br /> Tank # Size Product <br /> Facility Address : 1245 W Weber Ave, Stockto 10 , 000 Gasoline <br /> A 3 ► 000 Deisel <br /> Telephone: 948--7qvu <br /> Person Filing <br /> Report: Maida Olson <br /> I hereby certify under penalty of perjury that .all inventory variations <br /> for the above mentioned facility were within the allowable limits for <br /> this quarter . (Ivo 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 varia- <br /> tion was not due to unauthorized ( leak) release. (Yes in Column 13 of <br /> the Inventory Reconciliation Sheet) . <br /> List date, tank # , and amount for all variations that exceeded <br /> the allowable limits . <br /> Date Tank # Amount <br /> 1 . <br /> 2 . <br /> 3 . <br /> 4 . <br /> 5 . <br /> Additional dates/amounts shall be continued on a separate sheet <br /> paper and attached. <br /> If the source of the variation which exceeded allowable limits was <br /> due to a leak, the incident shall be reported to San Joaquin Local <br /> Health District; Environmental Health Division, within twenty-four <br /> ( 24 ) hours and an unauthorized release report submitted. <br /> The quarterly summary report shall be submitted within fifteen ( 15 ) days <br /> of the end of each quarter. <br /> Quarter 1 - January----------,March <br /> Quarter 2 - April------------>June <br /> Quarter 3 - July------------->September <br /> (E:te�r4 - October---------->December �p <br /> Send to: SAN JOAQUIN LOCALHEALTH DISTRICT <br /> 1601 E. Hazelton, P.O. Box 2009 F� Y ' <br /> 9 <br /> Stockton, CA 95201 4683420 'p 10 <br /> LH 23 019 10/86 <br />