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GLASROCK HOME HEALTH dkRe ' <br />705 INDUSTRIAL PARK DR. <br />MANTECA, CA 95336 INVENTORY RECONCILIATION <br />QUARTERLY SUMMARY REPORT FORM <br />Facility. Name: _GLAS�ol� //omE //Fg/��/ /We- <br />Facility''Address: 7pf ri✓Ovrrrl.nc pt- Ort_ <br />A <br />Telephone: ( 20y) 1-34- -I 1 0 {� <br />Person Filing <br />Report a , Z I k NTLI <br />OCT 16 1989 <br />ENVIRONMENTAL HEALTH <br />PERMIT/SERVICES <br />Tank I Size Product <br />2 an V vN Lr/J r <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. (Ho in Column 13 of 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) release. (Yea in Column 13 of the <br />Inventory Reconciliation Sheec) <br />List date, tank f, and amount for all variations that exceeded the <br />allowable limits. <br />Date Tank / Amount <br />2. <br />3. vAJ <br />4. <br />5. <br />Additional darts/amouacs shall be continued on a separate sheet of <br />Paper and attachcd. <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 Healch <br />Within 24 hours and an unauthorized release report submitted. <br />The quarterly sumaury 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 />anter ] - <br />Q--.Pcpccm .: <br />Quarto4 - ucEo0cC --Dcccmbcr <br />Send to: SAN JOAQUIN LOCAL HEALT[i DISTRICT <br />1601 E. 11azelt4m, P.O. Box 2009 <br />Stockton, CA 95201 466-6761 <br />Eli 23 019 10/86 <br />