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INVENTORY RECONCILIATION <br />QUARTERLY SUMMARY REPORT FORM <br />Facility Name:Vi2Ar.lr�sl����,��c }✓12r.� <br />Facility Address= S F. <br />C <br />Telephone: �. �. - C15' 7 <br />Person Filing <br />Report Irk tdc iAS Q <br />own <br />0 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 Colum 13 of the Inventory Reconciliation Sheet) <br />Inventory variations exceeded the allowable'lisits for this quarter. I <br />bereby 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 />Idventory Reconciliation Sheet) <br />List date, tank i, and amount for all variations that exceeded the <br />allowable lisiits. <br />Date Tank * ,Amount <br />ctz <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 allowable limits was due to <br />a leak the incident shall be repotted 'to S.J.L.H.D. Environmental Health <br />Within 24 hours and an unauthorized release report submitted. <br />The quarterly sussmary report shall be submitted within 15 days of the end of each <br />• quarter. <br />Quarter 1 - January --i March <br />Quarter 2 - April --> June <br />Quarter 3 - July --> September <br />Quarter 4 - October --> December <br />Send to: SAN JOAQUIN LOCAL. HEALTH DISTR4CT <br />1601 E. ltazelton, P.O. Box 2009 <br />Stockton, CA 95201 466-6781 <br />UCT 40 10/86 <br />