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INVENTORY RECONCILIATION <br /> QUARTERLY SUMMARY REPORT FORM <br /> N.O SAN/JS GtP. / <br /> Facility Name '7"&'7 / �rw�yfo d fade �'o lank f Site. PCOuuct <br /> D 0 0 7' <br /> fdeilit Addraut , oS T �citco�A�c ` z 8 eo • <br /> 7;>. ,•, it 9s3ad ooa u v�iroc� <br /> Escit co nl <br /> Telephone: )S35/339 <br /> Person Filing _ <br /> Report / /�g^j� <br /> I beceby certify under penalty of perjury that all inventory variations for <br /> the above mentioned facility were vithin the allowable limits for this <br /> Quarter. (No in Colum 13of the Inventory Reconciliation Sheet) <br /> Inventory variations exceeded the allovable limits for this Quarter. I <br /> hereby certify under penalty of perjury that the source for the variation <br /> was not due to an unauthorixed (leak) releiae. (Yes in Column 13 of the <br /> Inventory Reconciliation Sheec) <br /> List date, tank f. and ssouet for all variations that exceeded the <br /> allowable limits. <br /> Date Tank f Amount <br /> 2. PSR Z 1 H�P`�N <br /> 3. MENS Rv�CES <br /> 4. <br /> s. <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 due to <br /> a leak the incident shall be reported to <br /> S .J .L.H.D. Environmental Ucalch <br /> within 24 hours and an unauthorised release report submitted. <br /> The Quarterly summary report shall be submitted within I5 days of the end of each <br /> Quarter. <br /> Quarter 1 - January --> March <br /> Qaartar 2 - April June <br /> Quarter 3 - July --> Septemher <br /> ( .uartcr 4 - october December <br /> Send to: SAN JOAQUIN LOCAL HEALTIi DISTRIC1. <br /> 1601 E. siazeILnn . P .O . Ito .,( 2007 <br /> Stockton . CA 75201 466-6781 <br /> UGT 40 10/ 86 <br />