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i --,,RECEftD <br /> J U L 51991 <br /> INVENTORY RECONCILIATION ENVIRONMENTAL HEALTH <br /> QUARTERLY SUMMARY REPORT FORM PERMIT/SERVICES <br /> laeiLitr Naa.ei r lJL AZ21 /f, o dSank 0 Size Prouuct <br /> ldeiliey:.lddraa�t G� t Sch (CAI <br /> c C G ZEE Gcn/L <br /> Telephone: x-133 i <br /> Person Filing v <br /> Reportiy�aTr <br /> 0---i hereby certify under penalty of perjury that all inventory variations for <br /> the above mentioned facility xre v:r-hin. the allowable limits for this <br /> Quarter. (Ho in Column 13of the loventocy Reconciliation Sheet) <br /> E] Inventory variations exceeded the allowable limits for this quarter. L <br /> hereby certify under penalty of perjury that the source for the variation <br /> vas not due to an unauthorized (leak) releise. (Yes in Column 13 of the <br /> Inventory Reconciliation Sheet) <br /> List date. tank I. and amount for all variations that exceeded the <br /> allowable limits. <br /> Date Tack / Amount <br /> 1. i <br /> 1 <br /> 2- <br /> 3. <br /> 4. <br /> S. <br /> Additional dates/amouocs shall be continued on a separate sheet of <br /> paper and accnchcd_ <br /> if the source of the variation which. exceeded allowable limits was due to <br /> a leak the incident shall be repotted to <br /> S .J .L.H.D. Environmental licalch <br /> wiChin 24 hours Aad an unauchorired release report submitted. <br /> Itis quarterly summary report shall be submitted within 15 days of the end of each <br /> quarter. <br /> Quarter I - January March <br /> Quarter 2 - April --> June <br /> Quarter t - July --> September <br /> Quarter 4 - October December <br /> Send to: SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> L601 E. liazelLol) . P .O . ilex 200') <br /> Scockton . CA 95201 466-6761 <br /> UGT 40 10/ 86 <br />