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l <br />INVENTORY RECONCILIATION <br />QUARTERLY SUMMARY REPORT FORM <br />Facility Name;V S S CGm an <br />Facility;Addccsa; 639 W. Ctatf St. <br />Telephone: 2n9-949-n3AO <br />Person Filing <br />Report BG d Gnave� <br />0 <br />0 <br />1-5-88 <br />I hereby rectify under penalty of <br />the above perjury that all inventory variations for <br />s►entioned facility y were within the allowable limits for this <br />quarter. (mo to Column 13 of the Inventory Reconciliation Sheet) <br />❑ Inventory variations exceeded the allowable limits for this quarter. <br />hereby certify under penalty of perjury that the source for the variation <br />was not due to an unauthorized (leak) release. (Yes is Column 13 of the <br />Inventory Reconciliation Sheet) "-- <br />List date, tank 1, and amount for all variations that exc <br />allowable limits. ded the <br />Date Tank I <br />Amount <br />1. <br />--------- <br />- <br />4. <br />5 . --- <br />Additional dates/amounts shall be continued on a separate sheet of <br />Paper and attached. <br />If the source of the variation which. exceeded allowable limits was dui to <br />A 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 submitted within 15 days of the end of each <br />quarter. <br />Quarter I - January --> March <br />QUArter 2 - Apri l --) June <br />July --> Scptcmhc:r <br />Quarter 4 - October --) <br />comber <br />Send co: SAN JOAQUIN LOCAL HEALTH DISTRICT <br />1601 E. 11aze l t o�n , t' .0 , lic�x lcl(19 <br />�,U I O/Fib Stockton, CA 95201 466-6761 <br />�' <br />