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1-G-89 <br />INVENTORY RECONCILIATION `SAN 10 19 <br />89 <br />QUARTERLY SUMMARY REPORT FORM CV✓PE MIT SE2vis s�Tr° <br />Facility Naa►es <br />S 4 ('Irwnn�iG! <br />�acility:�tddress: •�39 w CPau S. <br />Stoakton Ca. 95206 <br />Telephone: 209-948-0302 <br />Person Filing <br />Report SOyd Gnovez <br />I hereby certify under Penaltyof <br />the above Perjury that all inventory variations for <br />s�cntioned facility were within the =!Ecwxble limits for this <br />quarto. (mo is iulum" "Of the Inventory Reconciliation Sheet) <br />QInventory variations exceeded the allowable limits for this <br />hereby certify under pcnalt f quarter. I <br />y. oPerjury that the source for the variation <br />wa■ not due to as unauthorized (leak) release. (Yes is Column_13 9f. the ... <br />Inventory Reconciliation Sheet) <br />List date, tank E, and amount for all variations that exceeded the <br />Allowable lic,its. <br />Date Tank R Amount <br />1. <br />4. <br />S. <br />Additional dates/:mounts shall be conCicucd -� <br />Paper and attached. - 4 'g -,►paste sheet of, <br />If the source of the variation which -exceeded <br />a allowable limits was due to leak the incident shall be reported to <br />Within 24 hours and an unauthorized release.report.D bmittedcottmental Ucalth <br />The quarterly suassary report shall be xubmitted within 15 days of the end of each <br />ch <br />Quarter t January :-) march <br />Q*larter 1 - April --> June <br />Quarter 3 - Juty --> September <br />Quacter 4 - October --> December <br />Send to: SAN JOAQUIN LOCAL HEALTH UISTRIC'1' <br />1601 E. . 11aze 1 t mi. V .0 . it ox 2000 <br />40 10/86 Stockton, CA X15201 466-G7b1 <br />1' <br />