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INVENTORY RECONCILIATION <br />QUARTERLY SUMMARY REPORT FORM <br />Facility Names I-px Jy,- <br />/���'�'� Tank i Site <br />facility Address: /�q7/ iDeov <br />' <br />Telephone: <br />Person Fi ing <br />Report <br />Product <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 />rivarter. (No is Column l3 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) releiae. (Yes in Column l3 of the <br />Inventory Reconciliation Sheet) <br />List date, tank /, and amount for all variations that exceeded the <br />allowable limits. <br />Date Tank It Amount <br />2. <br />3. <br />4. <br />5. <br />AM <br />(�E VE <br />J U L 1 0 1990 <br />L',aViRONMENTAL HEALTH! <br />PERMIT/SERVICES <br />�tia: <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 <br />a limits was dui to <br />leak the incident shall be reported to S.J.L.H.D. Environmental health <br />Within 24 hours and an unauthorized release report submitted. <br />me quarterly summary report shall be Rubmitted within 15 days of the end of each <br />quarter. <br />Quarter I - January --> March <br />Quarter 2 - April --> June <br />Quarter 3 - July --) Septemht!r <br />Quarter 4 - October --) Dvicewber <br />Send to: SAN JOAQUIN LOCAL HEALTH DISTRICT <br />160t E. Hazelton. 1' .0 . 1iOx !OO') <br />40 10/86SLockton. CA 95201 460-67b1 <br />