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INVENTORY RECONCILIATION <br />QUARTERLY SUMMARY RFPORI FORM <br />Facility Name: Ktoe� <br />rocR / <br />faeiiity Address: /56)L -A. r/ 1)6 -,r ln/J/a <br />-5 *f k i6n C,t 9 �/ <br />Telephone: clog y�ct_o�i9 <br />Person Filing <br />Report <br />a <br />CEIVE <br />J U L 16 'gn-1 <br />,A ENTAL HEEL,; T1 <br />!_ 1 TIT/SERVICE: <br />1 hereby certify under penalty of perjury that all inventory variatioas for <br />the above mentioned facility were within the allowable limits for this <br />+u" `" • %no sn LoIumm 00t the loveacory Reconciliation Sheet) <br />❑ iaventocy variations exceeded the allowable limits for thin quarter. L <br />hereby certify under penalty of perjury that the source for the variation <br />was not due to an unauthorized (leak) release. (Yes is Column 13 of the <br />Inventory Reconciliation Sheet) <br />0 <br />List date, tank f, mad amount for all variations that exceeded the <br />allowable limits. <br />Date Tank ! Amount <br />AddiCio^,! w• -•/a=:act': �':-!1 � <br />Paper and attached. <br />if the source of the variation which exceeded allowable limits was due to <br />a 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 />The Quarterly sum.n_ary report shall be submitted within IS days of the end of cath <br />7uarYer. <br />Quarter I - January --) March <br />--------------- <br />.a rt�•r - A r� l -- wu� /99� <br />Qua rtcr ) - Jwly __ Sep(cmhe.r <br />Qaartcr 4 - October --) December <br />Send to: SAN JOAQUIN LOCAI. HEALTI; DISI-RICI <br />1601 E. Hazclliul, V.0. h4ix 2.009 <br />SLockton• CA 95201 466-67bl <br />'CT 40 10/86 <br />