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INVENTORY RECONCILIATION <br /> QUARTERLY SUMMARY REPORT FORM ENpIERMj�SERViEP&-fH <br /> FaciLLty Name: SourH COuu ry farm: icu-st en. Tank / Size Product <br /> 16, 600 Su .:kF2 &AII <br /> Tacility,'Address: 13o5 EScALON AUE p 0. HA2 <br /> F.F.<�s_ Cn4 9.5''3 2 0 o on uAizA e 6 <br /> Telephone : 204/ R3A - 1339 <br /> Person Filing <br /> Report 7a✓i e. l L. CQIFFW <br /> &eneral P&rtner <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 13 of the Inventory Reconciliation Sheet) <br /> Inventory variations exceeded the allowable limits for this Quarter. t <br /> hereby certify under penalty of perjury that the source for the variation <br /> was not due to an unauthorized (leak) releise. (Yes in Colum 13 of the <br /> Inventory Reconciliation Sheet) <br /> List date, tank /, and amount for all variations that exceeded the <br /> allowable limits. <br /> Date Tank / Amount <br /> 1. <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. exceeded allowable limits was due to <br /> a leak the incident shall, be reported to S ,J .L.H . D . Env ironmentaL Mcalth <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 i - January --) March <br /> Quarter 2 - April --> June <br /> Quarter 3 - July --> September <br /> Quarter 4 - October --) December <br /> Send co: SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. Hazelton , P . O . Ros 2009 <br /> Stockton , CA 95201 466-67bl <br /> UGT 40 10/ 86 <br />