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INVENTORY RECONCILIATION <br />QUARTERLY SUMMARY REPORT FORM <br />Facility Name: M 0-C-" M <br />Facility Address: -jV/ (,V. k-pak.cAAa(V L,AOf <br />Low( C QA 4E9-4� <br />Telephone: —d2egg _ �� <br />Person Filin <br />Report <br />IECEIVEL, <br />APR 10 ,1"'1 <br />ENVIRONMENTAL HEALTH <br />PERMIT/SERVICES <br />ffl' 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 />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) releise. (Yes in Column 13 of the <br />Inventory Reconciliation Sheet) <br />List date, tank 1, and amount for all variations that exceeded the <br />allowable limits_ <br />Date Tank f 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 repotted 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 --> ticptcmher <br />Quarter 4 - October --) [}occmber <br />Send to. SAN JOAQII I N LOCAL HEAL'I'li DISTRICT <br />160 1 E. Haze I i (,n , 1' . 0. Box 2009 <br />SI_ockton, CA 95201 466-67b1 <br />'(;'1' 40 10/86 <br />