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i <br /> INVENTORY RECONCILIATION <br /> QUARTERLY SUMMARY REPORT FORM <br /> SOUTH COUNTY FOOD& FUEL C( , <br /> Eaciiity Name: MD SANDS CORPORATION Tank ! Sixa Pro..uct <br /> pu�M�FICL BOX 516 APE <br /> [atitity'44dresst ESCALON. CA95320 <br /> Telephone: 8.3s - 13.39 <br /> Person Filing <br /> Report +est elcltk S ��� r <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. (No in column 13of the loveatocy Reconciliation Sheet) - <br /> Inventory variations exceeded the allowable Limits for this quarter. I .. <br /> hereby certify under penalty of Mrjury that the source for the variation <br /> was not due to an unauthorized (leak) releise. (yes in Column 13 of the <br /> Inventory Reconciliation Sheet) <br /> List date. teak !s and amount for all variations that exceeded the <br /> allowable limits. <br /> Date Tank ! Amount <br /> 1. <br /> I <br /> 2. <br /> 3. <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. eaceeded allowable limits was due to <br /> a leak the incident shall be repotted to S .J .L.H.D. Env ironmentaL Health <br /> within 24 hours and an unauthorized release report submitted. <br /> The Quarterly summa,y report shall be submitted within 15 days of the end of each <br /> Quarter. <br /> Quarter I - Jaouary --) March <br /> Quarter 2 - April --> June <br /> Quarter 3 - July --> Scpccmhcr <br /> Q..arCer 4 - October --> December <br /> Send to: SAN JOAQUIN LOCAL HEAL1'li DISTKICT <br /> 1601 E . liazeILOn , P .O . Itos 2009 <br /> SLOCkton . CA 95201 466-6761 <br /> UGT 1.0 10/86 <br />