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v <br />1 INYENTORY RECONCILIATION <br />QUARTERLY SUMMARY RFPORT FORM <br />Facility Name 2 <br />4fft1mZ4) .a \±A <br />9fL_ Tank. <br />rAcUity Address: r16 20 W. r tcs4P rc� <br />Telephone: - <br />Person Filing <br />Report <br />Size I ,Product <br />1 hereby certify under penalty of perjury that all inventory variaCioae for <br />.be above nenCioned facility were within the allowable Limits for Chis <br />Quarter. (No in Column 13of the Inventory Reconciliation Sheer) <br />Inventory variation, exceeded the allowable limits for this Quarter. I <br />hereby certify under penalty of perjury Chit the source for the variacioa <br />vas DOC due Co an unauthorized (leak) release. (Yes in Colusam 13 of the <br />Inventory Reconciliation Sheet) <br />List date, Caok f, and amounC for all variation■ Chat exceeded the <br />allowable limits. <br />Dace Tank I Amoune <br />1. <br />4. <br />S. <br />RECE. <br />JAN 1 8 1990 <br />ENVNMENTAL HEA <br />PERMIT /SERVICES <br />AddLtiocal daCes/amouaCs shall be continued on A ,eparzcc sheet of <br />paper and attached. <br />If the source of the variation which exceeded allowable Limits was due Co <br />a leak the incident shall be reported cn S.J .L.H.D. Envirorunental llcalch <br />viChsn 24 hours and an unauthorl Led release reporC submsCted. <br />The Quarterly suoasary report shall be submitted with(, IS days of the end of oath <br />Quarter. <br />Qu ar('.r I - Jn.+rch <br />Q-,arc.7r 2 - April --> J.r..e <br />Q,.r(er j - July _! lCptcmh+'r <br />DCcnbCr --> Il.'c .-mhcr '871 <br />Send co: SAN JOAQUIN LOCAL HEALTH 01S'1'ItICT <br />1001 E . Hazelton. 1' . 0. R++s ', 007 <br />SLockron. CA 75201 466-6Ib1 <br />.0 10/Nh <br />