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• INVENTORY <br />RECONCILIATION <br />QUARTERLY SUMMARY REPORT FORM <br />Facility Name: ClJV11lf2YL/_ �(� ,SN6 L <br />Facility Address:2S; 5' MAV772X4LU4 <br />STvW7LA,_ c A 9 Ir 0 4 <br />Telephone: an% _ 9 0? , D ?;-;q <br />Person Fijin <br />Report: F�'H�N `7 /Z !r-rek%l <br />(�7 I hereby certify under penalty of perjury th'nventor <br />variations for the above mentioned facility <br />allowable limits for this quarter. (No in c )) <br />Inventory Reconciliation Sheet.) <br />0 C T 1 8 1990 <br />Inventory variations exceeded the allowabl4ENM#0WTALt" jg Ti -4 <br />�I quarter. I hereby certify under penaltyof�{{ <br />source for the variation was not due toauthor zthe <br />ec��(Teal <br />release. (Yes in Column 13 of the Inventory Reconciliation <br />Sheet) . <br />List date, tank #, amount for all variations and the reason <br />for exceeding the allowable limits. <br />Date Tank <br />1�u y Mo S UxOLP <br />2QUL'f %sf %g� Z U 2.000 <br />3 74 h 1Z �) 2 0 vc7 <br />6 5CP7 12A 1990 au z ow <br />Additional dates/amounts shall <br />sheet of paper and attached. <br />Amount <br />Reason <br />S 7/ (-A -r - <br />.S7i Q <br />S-7 / UT l <br />5,T) C -S <br />J-7/ 6t4rS <br />-S—T1 e—H � <br />be continued on a separate <br />If the source of the variation which exceeded allowable limits <br />was due to a leak, the incident shall be reported to Public <br />Health Services of San Joaquin County Environmental Health <br />Division, within twenty-four (24) hours and an unauthorized <br />release report submitted. <br />The quarterly summary report shall be submitted within fifteen (15) days of <br />the end of each quarter. Circle appropriate quarter. <br />Quarter 1 - January ---------- >March <br />Quarter 2 - April -------- <br />--->June <br />Quarter 3 - July ------------>September <br />Quarter 4 - October --------->December <br />Send to: SAN OAQUIN COUNTY PUBLIC HEALTH SERVICES <br />IRONMENTAL HEALTH DIVISI ,__ <br />1601 E. HameltQn, Box 2009 <br />S on, 201 <br />EH 23 019(10/89) (209) 468-3420 <br />_)7� 952 0 t <br />