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INYENTORY RECONCILIATION <br />QUARTERLY SUMMARY REPORT FORM <br />racLUty Name: NlCtligWy 17,#M61 <br />Faciliey,Address: 384r1V15s7-d11aNrL.4,Ve <br />'_TR�4['Y Cl9 9,5376 <br />Telephone: 20 l - 83.5- 8410 <br />Person Filing <br />Report 4w, IY1ule14/V * '1667- <br />�, APR � 1989 <br />F 1'` 1RONME SEa� GE <br />Tank f Size Product <br />A66 L/NGFr <br />19 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 Inventory Reconciliation Sheet) <br />ElInventory variations exceeded the allowable limits for thin quarter. I <br />hereby certify under penalty of perjury that the source for the variation <br />was not due to an unauthorized (leak) release. (Yen in Column 13 of the <br />Inventory Reconciliation Sheet) <br />List date. tank 1, and amount for all variatioea that exceeded the <br />allowable limits. <br />Date Tank I Amount <br />1. <br />2. <br />3. <br />4. <br />5. <br />Additional dates/Z.ouota shall be continued on a e�parate ahe_ct of <br />paper and aiCached. <br />If the source of the variation which -exceeded allowable limits was duc to <br />a leak the incident shall be reported to S,J.L.H.D. Environ:.nent.;l Health <br />within 24, hours and an unauthorixcd release report submitted. <br />The Quarterly sur cy report ahzil be submitted within 15 days of the end of each <br />Quarter. <br />Quzrrcr 1 - January --> March <br />lar er - April --> June <br />Quarter 3 - July --) Scptember <br />Quarter 4 - October --) December <br />Send Co: SAN JOAQUIN LOCAL HEALTH DISTRICT <br />1601 E. HazelLnn, P.O. Box 2009 <br />SLockton. CA 95201 466-6761 <br />TGT 40 10/86 <br />J <br />