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4P Y �gzav�o <br /> INVENTORY RECONCILIATION JAN 10 1989 <br /> QUARTERLY SUMMARY REPORT FORM ENVIRONMENTAL HEALTH <br /> r� PERMIT I SERVICES <br /> TzV- I ar k <br /> Facility Name: a ki Ig 5 IV-C U Size- 'product <br /> P,lb, /3 440 C) O Z4- <br /> Facility <br /> tFacility Address: e. f -7 2L4f' C1 <br /> Gs61 6V <br /> Telephone : 970 <br /> Person Fil ' <br /> Report <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 it, 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 /> vas not due to an unauthorized (leak) release. (Yes in Column 13 of the <br /> Inventory Reconciliation Sheet) <br /> List date, tank #, and amount for all variations that exceeded the <br /> allowable limits. <br /> Date Tank I Amount <br /> 1. <br /> z_ <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 al-lovable 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 --? March <br /> Quarter 2 - April --> -lune <br /> Quarter 3 - July --) September <br /> Quarter 4 - October December <br /> Send to: SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E . Haze l t-011 , P . O . B()x 11)()9 <br /> Scockton , CA 95201 466-67bt <br /> UGT 40 10186 <br />