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i <br />fv 0. <br />INVENTORY RECONCILIATION <br />QUARTERLY SUMMARY REPORT FORM <br />Iraciuty, Nam: ViLLAGE WEST {z <br />Denlamin F1011 <br />CA 9520X <br />Telephone: 4/7 fS-S-Y-2 <br />. <br />Filin�&— <br />Report <br />u�uu�uu u�uuu�■u� ■u�u� <br />Thereby certify under penalty of perjury that all inventory variations for <br />the above mentioned facility were within the allowable limits for this <br />quartan. (No in Column 13 of the loventory 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 unauthorised (leak) release. (Yes in Col 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 />APR 3 01992 <br />Fj i / <br />�V 5��� NTV7jf, <br />a s t,'d <br />Additional dates/amcuats shall be continued on a separate sheet of <br />paper and attached. <br />if the source of the variation which. exceeded ai•lowable 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 --> September <br />Quarter 4 - October --> tk-cember <br />Send to: SAN JOAQUIN LOCAL HEALTH DISTRICT <br />1601 E. Hazelton. P.O. Rox 2009 <br />SLockton, CA 95201 466-6761 <br />UCT 40 10/86 <br />