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INVENTORY RECONCILIATION <br /> QUARTERLY SUMMARY REPORT FORM <br /> FaciLity. Nacres ZA <br /> .. rank Size. <br /> Product <br /> lsciltrAddresss , �C�% <br /> n cg G7,7 y <br /> Telephone : - 91-11- 21"Cly <br /> Person Filing <br /> Rep o r t %Dam -j?e S n✓, //e <br /> I hereby certify under penalty of perjury that all inventory variations for <br /> the above .aentioacd facility were within t..e L7lioiiaulc aia:its ani this <br /> quarter. (No in Column 13 of the Inventory Reconciliation Sheet) <br /> � 11.ventory variations exceeded the allowable limits for this quarter. T <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 13 of the <br /> Inventory Reconciliation Sheet) <br /> List date, tank 1, and amount for all variations that exceeded thq-, <br /> allowable Limits. t <br /> Date Tank f Amount <br /> q to <br /> 4cn , <br /> pF�"V, <br /> ell <br /> 3. <br /> 4- <br /> .55. <br /> . /L--" - L� - �i� <br /> Additional dates/2=e:atz shzil be cc.ntinued ou a zcp2rate &beet of / <br /> paper and attached. <br /> If 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. Environmental Health <br /> within 14 hours and an unauthorized release report submitted. <br /> The quarterly summary report shall be Rubmitted within 15 days of the end of each <br /> quarter. <br /> Quarter I - January --) March <br /> Quarter 2 - April --> June <br /> Quarter 3 - July --> September <br /> Quarter 4 - October --) December <br /> Send to: SAN JOAQU IN LOCAL HEALTH DISTRICT <br /> 1601 E , haze 1 <<�n , P . O . Box 2009 <br /> SLockton ,- CA 95201 466-6761 <br />::T 40 10/86 <br />