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INVENTORY RECONCILIATION <br />QUARTERLY SUMMARY REPORT FORM <br />Facility Name: ,eDi.Url /�f.ur�.e A&I"0A <br />Facility Address; Ao' c"-. / -.eD/- .,Y' <br />rocs-�, 9s26y <br />Telephone: 0 9- V/G s 4si,S- <br />Person Filing,, <br />Report <br />Tank I Site <br />Product <br />/� boa <br />la.e <br />2 <br />? yy <br />3 /R Doo <br />,uL Su .ear <br />9 <br />3. 9/7/S 7 <br /></1 <br />4. 912;71,e <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. I <br />hereby certify under penalty of perjury that the source for the variation <br />was not due to an unauthorized (leak) reles'se. (Yes in Column 13 of the <br />Inventory Reconciliation Sheet) <br />List date. tank I, and amount for 21L variations that exceeded the <br />allowable limits. <br />Date <br />Tank I <br />Amount <br />1. 913167 <br />2 <br />? yy <br />z. 9/5/8 7 <br />2 <br />9 <br />3. 9/7/S 7 <br /></1 <br />4. 912;71,e <br />3 <br />5. 1112819 7 <br />2 <br />/-S- <br />Additional dates/amounts &hall be continued on a separate sheet of <br />paper and attached. <br />If the source of the variation which exceeded allovable 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 />T'he Quarterly summary report shall be Fubmitted within 15 days of the end of each <br />Quarter. <br />Quarter I - January --) March <br />Quarter 2 - April --> June <br />Quarter 3 - July --> septcmher <br />Quarter 4 - October --) I>rcember <br />Send to: SAN JOAQII IN UWAL HEALTH DISTRICT <br />1601 E. 1',aze1t-n, 1'.0. hox )009 <br />Stockton, c:A 95201 466-67b1 <br />-1t l' 40 10/86 <br />