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INVENTORY RECONCILIATION <br />QUARTERLY SUMMARY RF_PORT FORM <br />Facility Name: I L �� _ '` _ s yy <br />Facility Address: c J <br />J'lv 1. <br />Telephone: ci Sl4 I <br />Person Filing <br />Report Ccs• oA 0A,- k= <br />RECEIVED <br />J U L 1 8 1990 <br />ENVIRONMENTAL HEALTH <br />PERMIT/SERVICES <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 13of the Inventory Reconciliation Sheet) <br />ElInventory 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 am unauthorized (leak) release. (Yes in Column 13 of the <br />Inventory Reconciliation Sheet) <br />List date, tack 1, and amount for all variations that exceeded the <br />allowable limits. <br />Date Tank I Amount <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 />Quarter I - January March <br />Quarter 2 - April --> June <br />Quarter 3 - July __> ScpCcmber <br />Quarter 4 - October --> December <br />Send to: SAN JOAQUIN LOCAL HEALTH DISTRICT <br />1601 E. llazelLon, P.O. Box 2009 <br />llG'I' 40 10/86 SLockron, CA 95201 466-6781 <br />