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ENTORY RECONCILIATION <br />QUARTERLY SUMMARY REPORT FORM <br />RICHAPM ECKIRES <br />Facility Nave: SAW'},f Ci!TV CKWROM <br />0 <br />INTERSTATE S & HIWAY 12 <br />Facility Address: i nni r" A W QiQ49��'�� <br />i')noti VzQ_n07r <br />Telephone: <br />Person Filing <br />Report { <br />4. <br />Tank # <br />Size <br />Product <br />I hereby certify under penalty of perjury that all inventory variations for <br />the above mentioned facility were within the allarable limits for this <br />quarter. (leo in column 13 of the Inventory Reconciliation Sheet) <br />Inventory variations exceeded the allowable liaits for this quarter. I <br />hereby certify under penalty of perjury that the source for the variation <br />was not due to an unauthorised (leak) release. (Yes in Colu=13 of the <br />Inventory SAconciliation Sheet) <br />List date, tank #, and amount for all variations that exceeded the <br />allowable limits. <br />Date Tank # Amount <br />2. <br />3. <br />4. <br />S. <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 ailwablc limits was dun 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 />b-tt—ee—rr <br />1January --> March 2 - April --> June <br />Quarter 3 - July --> September <br />Quarter 4 - October --> December <br />Send to: SAN JOAQUIN LOCAL HEALTH DISTRICT <br />1601 E. Hazelton, P.O. Box 2009 <br />Stockton, CA 95201 466-6781 <br />UG`1' 40 10/86 <br />