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INVENTORY RECONCILIATION <br /> QUARTERLY SUMMARY Rf_PORT FORM 1CI 1 eAtTH <br /> „-.pd1F'h S <br /> Facility Name: jY7 '9 p (�jtHaq��O�(�! `� tank 1 ,E1<t'P�ii� Product <br /> Facility Address: by'y o _ /iJ.OdU �; <br /> /, <br /> Telephone ! f y3 —,2t^Z <br /> PersonFili g <br /> Reporteriilvi <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 13of the inventory Reconciliation Sheet) <br /> E] 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 in Column IJ of the <br /> Inventory Reconciliation Sheet) <br /> List date, tank 1, and amount for all variations that exceeded the <br /> allowable limits. <br /> Date Tank I Amount <br /> I. <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 vas due to <br /> a leak the incident sha11 be reported to S ..I .i..R. U . F.nviromxntnl health <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 --) Harch <br /> (riarter 2 - April --> June <br /> Qiarter 3 - July --) September <br /> Quarter 4 - October. --) December <br /> Send to: SAN JOAQUIN LOCAL HEALTH ULS'rmur <br /> 1601 F. . 11azc l ton , I' .0 . I'" 2009 <br /> Stockton , CA 95201 466-6781 <br /> 11GT 40 10/86 <br />