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40 *- I I to <br />IUVEUTORY ItECONCILIAIIOU <br />QUARTERLY SUMMITRY IMPORT- FORM <br />Facility Name: <br />Cir C \0 <br />Facility Address: '-'419 �. <br />�p�p,._TS33 <br />Telephone- _2. 0� <br />Person Filin <br />Reportr,,^� <br />rank 1 <br />Size <br />Product <br />_ <br />RM()- <br />- <br />,bon <br />--AZ-Wo <br />.1,000 <br />U V, laa& o�\ <br />M4\a.✓ <br />3_ <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 />ElInventory variations exceeded the allowable limits for this quarter. I <br />hereby certify under penalty of perjury that tl,e 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 date, tank 1, and amount for all variations that exceeded tile` <br />allowable limits. <br />Date ank f Amount a^�" <br />1. �i l <br />3. <br />4. <br />5. <br />Additional dates/amounts shall be continued on a separateSheetof <br />paper and attached. <br />If the source of the variation which exceeded allowable limits was du(! to <br />a leak the incident shall be reported to S„ j ,1,.11.1). Enviro,unental health <br />Within 24 hours anu an u;,authorized release report submitted. <br />The quarterly summary report shall be submitted within 15fdays of the end of each <br />quaker. <br />Quarter_ I - January N,rch I <br />Q�lartcr 2 - April <br />Quarter 3 - July --> Sr.ptemher <br />Quarter 4 - October --> December <br />Send to: SAN JOAQUIN LOCAL HEALTH UI.s-ri ur <br />1601 E. I'Mze licit► , 1' .O . ")" 2009 <br />Stockt-on , CA 95201. 60 6-6781 <br />UG,r 40 10/86 <br />