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INVENTORY RECONCILIATION OCT 5 1987 <br /> QUARTERLY SUMMARY REPORT FORM <br /> ENVIROMENTAL HEALTH <br /> \ FERMIT/SERVICES <br /> 7' �U/�' <br /> Facility Name• A,�//y L�L! WVir Tank / Size Product <br /> ,:-� U <br /> Facility Address: 180(( 41• "AzJ <br /> Telephone : •/63 -Z 4<A.3 <br /> Person Filin <br /> Reportc�a��tL X�he <br /> 1 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 /> ElInventory 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 211 variations that exceeded the <br /> allowable limits. <br /> Date Tank / 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 /> WtChin 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 --) September <br /> Quarter 4 - October --) fkcember <br /> Send to: SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E . Hazeltiin . P .O . Box 2009 <br /> SLockron • CA 95201 466-6761 <br /> UCT 40 10/ 86 <br />