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l <br />INYENTORY RECONCILIATION <br />QUARTERLY SUMMARY REPORT FORM <br />Facility Name: <br />_ -c <br />Tank I Size Product <br />Facilit Address: G39 lw. � - <br />y` Clay Spee unleaded <br />13- 2Gat cii e/s e.2 <br />Telephone; 948-0302 G' 000 GaQ dies et <br />Person Filing a�teo.it'_ 1 000 Gat wa tea <br />Report Boyd Gnaved <br />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. (Ko in Column 13 of the Inventory Reconciliation Sheet) <br />QInventory 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 &a unauthorized (leak) release. (Yes in Column 13 of the <br />Inventory Reconciliation Sheet) <br />List date, tank /, and aswunt fer all variations that exceeded the <br />allowable limits. <br />2. <br />3. <br />4. ------- <br />---------- ------- ---- <br />Additional dates/amounts shall be continued on a separate sheet of <br />Paper and attached. <br />LE the source of the variation which. exceeded allowable limits wase co <br />a leak the incident shall be reported to $,J L.N.D. Environmental Health <br />24 hours and an unauthorized release report submitted. <br />The quarterly summary report shall be submitted within IS days of the end of each <br />quarter. <br />Quarter I - January --> March <br />Quarter 2 - April --> June s s ,,, 44 <br />r <br />Quarter 3 - July --> Septcmh<!r � <br />Quarter 4 - October --) December` <br />2q, 10 <br />cn to: SAN JOAQU IN LOCAL HEALTH DISTRICT <br />1601 E. ttazc i t �s►i t' . O . lac ,�O�� �i <br />110 10/86 Scockton. CA 95201 466-67b1 <br />�. <br />