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C K <br /> APR 6 ^'� <br /> NVIRONMENTAL HEALTH <br /> PERMIT/SERVICES <br /> INYENTORY RECONCILIATION <br /> QUARTERLY SUMMARY REPORT FORM <br /> t -r I ' ^u+JTy FODD FUEL o. Tank 9 Size Pro ucc <br /> Facility Names so <br /> 10, 000 S" ar 1,n4e.Ad <br /> Paeility''Addresss 1305 S. Ere�lara ASE, o00 2 wear <br /> . .• �" ��eA(.Oh7 GA 4C3z0 �3 "ig ovo uhIG 4Q e �1 <br /> Telephone: .oa l 5�8-1335 <br /> Person Filing <br /> Report I) L G RiFr ti <br /> L hereby certify under penalty of perjury chat All inventor/ variations for <br /> the above mentioned facility were within the allowable limits for this <br /> quarter. (No in Coluasa 13of the Loveacary Reconciliation Sheet) <br /> Inveatocy variations exceeded the allowable limits for this quarter. L <br /> hereby certify under penalty of Krjury that the saurca for the variation <br /> was moc due to an unauthorized (leak) release. (Tet in Column 13 of the <br /> Inventory Aeconcilistion Sheec) <br /> List dace, tank 1, and amount for all variations chat exceeded the <br /> allowable limits. <br /> Date Tank / Amount <br /> I. ' <br /> 3. <br /> 4. ; <br /> Additioaal shall be continued oo a " sra ce sheet of <br /> paper and attached. <br /> It the source of the variation which, cxcccdcd allowable E li iitsnvronwas duHeto <br /> lth <br /> a leak the incident shall be reported to S .J .L.H .D. <br /> within 24 hours and an unauthorized release report submitted. <br /> The quarterly summary reporc shall be aub.itted within IS days of the end of each <br /> quarter. / <br /> V Quarter I - January --) March <br /> Quarccr 2 - April --) June <br /> Quarter 3 - July --> September <br /> Qu arccr 4 - <br /> October --) December <br /> AN JOAQUIN LOCAL HEAL3'li DISTRICT <br /> Sena to: S <br /> E. Hazelton , P .O . NON 2009 <br /> 1601 <br /> SLockcon , CA 95201 466-67b1 <br /> UCT 40 10/ 86 <br /> Lf the source of the variation which. ezceeded 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 a,b.itc,d. <br /> Lhc quarterly sammary report shall be submitted within 15 days of the end of each <br /> quarter. <br /> Quarcer 1 - January --) March <br /> QQaarter 2 - April --> June <br /> ✓ Quarter 3 - July --) September <br /> Quarter 4 - October --) December <br /> Send to: SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. IiazelLim , P .O. Ilos 2009 <br /> SLockcon , CA 95201 466-67b1 <br /> OCT 40 10/H6 <br />