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`IVa L) <br /> �r Dia <br /> INVENTORY RECONCILIATION SEC 5 <br /> uN\J',Ro 4 ! s��vicEs TF1 <br /> QUARTERLY SUMMARY REPORT FORM <br /> PERMIT I <br /> Facility Name: Tank / <br /> Sire Product <br /> Facility 'Address: �'IJ ,�o)C /e 'l7ofii� s 4- <br /> 6W 6W a� <br /> Telephone : <br /> Person Filing S y �000 6Xt <br /> Report ✓ <br /> �-/J1R� iYi� it �,c2 Gk - -SL <br /> EK <br /> 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. (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 /> pDate Tank I Amount <br /> 1. Z <br /> 2. 7� /F V <br /> 3. <br /> 4. <br /> S. <br /> Additional dates/amounts shall be continued on a separate sheet of <br /> Paper and attached. <br /> If the source of the variation vhich. exceeded al,lowable Limitswasdue to <br /> A leek the incidentshallbe- re Ported to S .J .L.H. D.. EnvironmentaL .11calth <br /> within 24 hours and an unauthorized telease report submitted. <br /> I-hc quarterLy s,.,,y -report shall -be'submi Cted within 15 days of the end of. each - <br /> quarter_ . <br /> Quarter 1 - January --) March <br /> Quarter 2 April --) June: <br /> Quarter 3 - July --) SePtcmher - - <br /> Quarter 4 -- October --) l><cember - - <br /> Send to: SAN ,1.GAQUIN LOCAL HEALTH UISTRIC-1• - <br /> 1601 E. 1!aze l t „n , 1, .O _ ROs 2009 <br /> Stockton , CA 95201 466-6761 <br /> CT 40- l0/R6 � - <br /> ` -- <br />