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AMLIVt <br />0 C T 2 8 1991 <br />ENTAL HEAT TI -i <br />INVENTORY RECONCILIATION =X,VIRONIV, <br />PERMIT/SERVICES <br />QUARTERLY SUMMARY REPORT FORM <br />Facility Name: �zCp,41CJ J4„/ <br />Facility Address: -go <br />Telephone: ;2o g <br />Person Filin <br />Report ,) <br />Tank f Size Product <br />D OOU <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 Sheft) <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 unauthorized (leak) releine. (Yes in Column 13 of the <br />Inventory Reconciliation Sheet) <br />List date, tank f, and amount for all variations that exceeded the <br />allowable limits. <br />Date Tank E Amount <br />2. <br />3. <br />4. <br />5. <br />Additional dater/amounts shall be continued on a separate sheet of <br />paper and attached. <br />If the source of the variation whichexceeded 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 --> Harch <br />Quarter 1 - April --> June <br />Quarter 3 - Jtrly --> icptcmhcr <br />Quarter 4 - October --> Drccmhcr <br />Send to: SAN JOAQUIN 1,0CAI, HHA1.11i DISTRICT <br />160L 1:1. Haze 1 t cin , P.O. Box 2000 <br />SLockton, CA /5201 466-6781 <br />W;T 40 10/86 <br />