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**VENTORY RECONCILIATION <br />QUARTERLY SUMMARY REPORT FORM <br />Facility Name: <br />nr.a��n�S <br />Facility Address: S4e.ric E C".'Q! � , .1r;nl1 <br />6421 PPD ")rK '�' ACF <br />IN <br />Telephone: <br />Person Filing (209) 334-0975. <br />Report <br />WNW-JIM.,- <br />��MEN M1 I I <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 />QInventory 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 unauthorised (leak) release. (Yes in Column 13 of the <br />Inventory Reconciliation Sheet) <br />List date, tank #, and amount 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 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 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 />art- January --> March <br />Quarter 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 />UGT 40 10/86 <br />