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INVENTORY RECONCILIATION <br /> QUARTERLY SUMMARY RFPORT FORM <br /> Facility Name: /r,;/!s <br /> �� ��� MkISitu Product <br /> Facility;Address; �SO — DD p moo, <br /> • S� ehT� o� C%, <br /> Telephone : <br /> Person Filing <br /> Report <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 I3of the Inventory 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) releise. (Yes in Column 13 of the <br /> Inventory Reconciliation Sheet) <br /> List date, tank !, and amount for all variations that exceeded the <br /> allowable linits_ <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 /> It the source of the variation whichexceeded allowable limits was due to <br /> a leak the incident shall be reported to S .J . L . H . D . Environmental licalth <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 D � �(ylp ''moi <br /> Qaa iter 2 - April --> June \1e.19 I'''Lvll ll <br /> Quarter 3 - July --) Sep[cmber p V <br /> Quarter©- October --> December FEB 3 1988 <br /> Send to: SAN JOAQUIN LOCAI, HEALTIi DIS'I'MC'1' <br /> ENVIkOMENTAL HEALTH <br /> 1601 K . Naze I t (,n . P . O . hox 2009 PERMIT/SERVICES <br /> Stocft0. con . CA 95201 466 - 67bl <br /> 40 Inia6 <br /> r <br />