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.NYENTORY RECONCILIATION . <br /> QUARTERLY SUMMARY REPORT FORM <br /> Facility. Name: LF--Ae S Am-PAA I//Y/ — Tank A ... Size: .. <br /> Product, <br /> O(} <br /> Pacility•,Addresa:; ,• R�J— ,_ �'• ,L.py/SF ��� �2 �'• �D. �L?�- <br /> Telephone : D 61Z 2 <br /> Person Filing <br /> Report �0HA <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. (No in Column 13 of the Inventory Reconciliation Sheet) <br /> QInventory variatioas 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 1, and amount for all variations that exceeded the <br /> allowable limits. <br /> Date Tank ' f Amount <br /> OCT 2 9 1992 <br /> z. t NVRON+Vii."NTAL HEALTH <br /> 3. PE:RNu F/SCfiVICLS <br /> 4. <br /> S. <br /> Additional dates/amountx shall be continued on a separate sheet of <br /> paper and attached. <br /> If the source of the variation vhich. excecded a1•lowable limits was due to <br /> A leak the incident shall be reported to S .J .L.H . D . Environmental 11ealCh <br /> within 24 hours and an unauthorized release rcporc submitted. <br /> The quarterly summary report shall be r.ubmitted vithin IS days of the end of each <br /> quarter. <br /> Quarccr I - January --> March <br /> Quarter 2 - April --> June <br /> arter ] - July --> SePCcmhrr� <br /> Quarter 4 - Octobcr --> (k:ccT mber <br /> Send to: SAN JOAQUIN LOCAL •H.E;ALTH DISTRICT <br /> 1601 1: . Haze 1 Lo n , P . 0 . 1 ox 2009 <br /> SLockton . (.A -95201 466-6781 <br /> UCT 40 10/ 86 <br />