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OVENTORY RECONCILIATION <br />QUARTERLY SUMMARY REPORT FORM <br />Facility Nacre: eee•NsIR4 99911s" <br />SA.DDLf CITY CHEVRONFacility Address: 960 n n Ol 4L6 <br />Ir-6-96041 <br />TCRCTATF 5 P. xiWAY 12 <br />Telephone: LODI, CALIF. 95240 <br />Person Filing <br />Report <br />Z. <br />Tank # Size <br />Product <br />1. <br />2. <br />3. <br />4. <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) release. (Yes in Column 13 of the <br />Inventory Reconciliation Sheet) <br />List dater tank #, and seeeouat for all variations that exceeded the <br />allowable limits. <br />Date Tank # Amount <br />1. <br />2. <br />3. <br />4. <br />5. <br />Additional dates/amounts shall be continued on a separate <br />sheet 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 <br />Health <br />within 24 hours and an unauthorized release report submitted. <br />The quarterly summary report shall be submitted within 15 days of the <br />end of each <br />quarter. <br />Quarter- - January --> March <br />��Quarter 2 - April --> June <br />n a <br />Quacte" - July --> September <br />Quarter 4 - October --> December <br />i <br />Send to: SAN JOAQUIN LOCAL HEALTH DISTRICT <br />�ji <br />1601 E. Hazelton, P.O. Box 2009 <br />?T w <br />Stockton, CA 95201 466-6781 <br />UGT 40 10/86 <br />