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INVENTORY RECONCILIATION <br /> QUARTERLY SUMMARY REPORT FORM <br /> SOUTH COUNTY FOOD&FUEL CO. <br /> Facility Name: MDSANI)SCO Tank # Size Product <br /> RPORATION <br /> POST OFFICE BOX 516 <br /> Facility Address: WhON, 6A 95320— 000 Cb <br /> Telephone : 111�21-7979-T-71-73190 <br /> Person Filing <br /> Report J. /✓/q/VT — <br /> NI 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. (Ho in Column 13 of the Inventory Reconciliation Sheet) <br /> 0 Inventory 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 an unauthorized (leak) release. (Yes in Column 13 of the <br /> Inventory Reconciliation Sheet) <br /> List date, tank 1, and amount for all variations that exceeded the <br /> allowable limits. re® xr "' <br /> Date Tank / Amount EIV t 2 <br /> 1, JAN 1 0 Inni <br /> z. ENVIRONENTAL PERMIT//SERVICESL�H <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 vzviaticn which exceeded allowable limits was due 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 1 - January --> March <br /> Quarter 2 - April --> June <br /> Quarter 3 - July --) September <br /> Quarter 4 - October --> December <br /> Send to: SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E . Hazelton , P .O . Box 2009 <br /> Stockton , CA 95201 466-6781 <br /> UGT 40 10/86 <br />