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INVENTORY RECONCILIATIONS <br /> QUARTERLY SUMMARY REPORT FORM <br /> FACILITY NAME: Organizational Maintenance Sh&f 0tZ4_? <br /> FACILITY ADDRESS: 8010 S. Airport Way <br /> Stockton, CA 95206-3919 <br /> (209) 982-4416 <br /> ATTN: CW4 Jones or SSG Burns <br /> TANK # 1: 5, 000 Gallon - Diesel #2 <br /> TANK # 2 : 10, 000 Gallon - Unleaded Gas <br /> I certify under the penalty of perjury that all inventory <br /> variations for the above facility were within the allowable limits for <br /> this quarter. <br /> Inventory variation exceeded the allowable limits for this <br /> quarter. I hereby certify under the penalty of perjury that the source <br /> of variation was due to unauthorized (leak) release . <br /> DATE TANK # AMOUNT <br /> 1. <br /> 2 . <br /> 3 . <br /> (ADDITIONAL INFORMATION MAY BE CONTINUED ON A SEPERATE PAGE AND <br /> ATTACHED) <br /> If the source of variation was due to a leak the incident shall be <br /> reported to SJHD - ENVIRONMENTAL HEALTH within 24 hours and an unauth- <br /> orized release report submitted. <br /> Quarterly summary report shall be submitted within 15 days of the end <br /> of each quarter. DATE OF THIS REPORT: 28 Sep 95 (3rd Quarter 95) <br /> SEND TO: San Joaquin Local Health District <br /> ATTN: Environmental Health <br /> 445 N. San Joaquin St <br /> Stockton, California <br />