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E EI V E 0tw, <br /> , <br /> INVENTORY RECONCILIATION APR 17 1991 <br /> t NVIRONMEI.~ir,4 H`-AJHT <br /> QUARTERLY SUMMARY REPORT FORM PEMvi , _) <br /> r <br /> Facility NameTank f Size Product <br /> �7i %��-�-� �ice`%t;,t,'C� ��afC'�!-�icE - <br /> Facility Address: ,7jol' R' A-- <br /> Telephone r-1 3 <br /> Person Filing <br /> Report a.yC Tr'�ce 1' <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 /> quarier. (No in Calumn 13 of the Invenr.ory Reconciliation Sheet) <br /> E] 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) release. (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 f Amount <br /> 1. <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 „) .L . H . D . Environmental Health <br /> within 24 hours and an unauthorized release report submitted. <br /> The quarterly summary-re-port shall be submitted within 15 days of the end of each <br /> quarter. <br /> / `QUarter I - January --) March <br /> c� Qnartcr 2 = Aprt L --> Junc <br /> / Quarter 3 July --) September <br /> Quarter 4 - October --> December <br /> Send to: SAN JOAQUIN LOCAL HEALTH DIS' Ricr <br /> 1601 E . 11aZC 11 on , P .0 . Box 2()()9 <br /> Seockton , CA 95201 466-67bl <br /> DICT 40 10/ 86 <br />