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I <br /> APR 19-3989 <br /> INVENTORY RECONCILIATION I <br /> QUARTERLY SUMMARY REPORT FORM C1, PERMIT/SERVICES ENTAL LTH <br /> Faetiitr Names 3aurm Cb.,.,ty on Fur, e-• Tank I Size, Pro uet <br /> taeilit AW •Z i o4a, a c4«Ia <br /> y Address /nee i..�-_ <br /> Telephone : 838 - 1339 <br /> Person Filing <br /> Report AIR. � , L , a ,. ) IFt=1Aj <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 /> quarter. (No in Colum 13of the Inventory Reconciliation Sheet) <br /> Inventory variations exceeded the allowable limits for this quarter. I <br /> bereby certify under penalty of pgrjury that the source for the variation <br /> was not due to as unauthorized (leak) release. (yes in Column 13 of the <br /> Inventory Reconciliation Sheet) <br /> List dater tank f. and amount for all variations that exceeded the <br /> allowable Limits. <br /> Date Tank / Amount <br /> I_ <br /> 3. ' <br /> 4. <br /> 5. .. <br /> Additiooal dates/amounts shall be continued on a separate sheet of <br /> paper and attached. <br /> It the source of the variation uhich. 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 cy report shall be submitted within 15 days of the end of each <br /> Quarter. <br /> Quaccer I - January --> (larch <br /> Quarter 2 -Aprzf -ls Ju G <br /> Quarter I - July --> September <br /> Q Amer 4 - October --> December <br /> Send to: SAN JOAQUIN LOCAL HEALTli DISTRICT <br /> 1601 E. HazelLun , P .O. Box 2007 <br /> SLockton • CA 95201 466-6761 , <br /> OCT 40 10/ 86 <br />