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` re mA V'IN! MARKET #21136 <br /> 3212 N. CALIFORIkll.^. ST. <br /> INVENTORY RECONCILIATION STOCKTON, CA "204 <br /> QUARTERLY SUMMARY REPORT FORM <br /> FacWtjr. Names rank f <br /> Size. Product <br /> /C <br /> Facililtr:Address: �r <br /> -- �� AlA/ Ccs/ ;j��o <br /> . <br /> Telephone : <br /> Person Filingg <br /> Report <br /> ❑ I hereby certify under penalty of perjury that all inventory variations for <br /> the above mentioned faciiity were within the ailowable 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) 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 listits. <br /> Date Tank f Amount +�yy <br /> 2. <br /> 3. <br /> 4. . ` y - C� / — r�4��i 0113if1i �Lr <br /> U <br /> !�ddityoCal w2te3I:�ounte Sh4l1 bc continucd on a zcparate 2hez: of <br /> J <br /> paper and attached. � <br /> If the source of the variation which. erceeded allowable 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 /> The Quarterly summary report shall be submitted within 15 days of the end of each <br /> Quarter. <br /> Quarter I - January --) March <br /> Quarter 2 - April --) June <br /> Quarter 3 - July --> Scptcmh(:r <br /> Quarter 4 - October --> December <br /> Send to: SAN JOAQUIN LOCAL HEALTH DIS'1'KICT <br /> 160L .H . haze 1 L o�n , P .O . Rox 2009 <br /> SLockton ,- CA 95201 466-6181 <br />.;T 40 10/ 86 <br />