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INVENTORY RECONCILIATION <br />QUARTERLY SUMMARY'REPORT FORM <br />Facility Haaee: 0g0f AJJA Nldh1WXY 17,47W06 <br />Facility Address: 3SSLuSTCKi4NTL//1/N- <br />-Fzgey CN 95376 <br />Telephone. z09 - 835- 89ZD <br />Person Filing <br />Report /(.(U, MaLleyyy " Y467-- <br />Tank <br />46Z <br />Tank f Size Product <br />e L/N'Z- <br />19 <br />- <br />19 L 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. (Y.o in Colum 13 of the laventory Reconciliation Sheet) <br />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 ie Column 13 of the <br />Inventory Reconciliation Sheet) <br />List date, tank /p and amount for all variatioea that exceeded the <br />allowable limits. <br />Date Tank f <br />2. <br />3. <br />4. <br />5. <br />Amount <br />P� <br />Additioaul dacesl-"Iuata shall be continued on a separate aka -:et of <br />paper and attached. <br />Lf 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. Eavironan;ntz.1 Hcalch <br />Within 24 hours and an unauthorized release report submitted. <br />The quarterly sucnary report shr.11 be submitted within 15 day_, of the end of each <br />quarter. <br />a ter I - January --) March <br />Chatter 2 - April --> June <br />Quarter 3 - July --) Scpccmhcr <br />Quarter 4 - October --) Oecember <br />Send co: SAN JOAQUIN LOCAL HEALTIi UISTR ICT <br />1601 E. linzelLnn, P.O. SOX 2009 <br />SLock Con. CA 95201 466-678L <br />:T 40 10/86 <br />6 <br />