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INYENTORY RECONCILIATION <br />QUARTERLY SUMMARY REPORT FORM <br />FaciLity Name: C19UFORIUiq NreNfuoY 17f37;1oC <br />iacility'Address: 39S v1 SiCRj4NrZ1&tr <br />SR14dY CA 9.6'376 <br />Telephone: 201 - 835- 89ZO <br />Person Filing <br />Report /I.6[l, mauley)y "'YGLZ <br />RECEIVE <br />JUE 2 6 19,00 <br />ENVIRONMENTAL HEALTH <br />PERMIT/SERVICES <br />Tank i Size Product <br />G-�120000we UNG F c <br />19 I hereby certify under penalty of perjury that all inventory variations for <br />the above uencioned facility were within the allowable limits for this <br />quarter. (no <br />"in Column 13 of the Inventory Reconciliation Sheet) <br />ElInventory variations exceeded the allowable limits for Chin quarter. I <br />hereby certify under penalty of perjury that the source for the variation <br />was not due to ac unauthorized (leak) release. (Yea in Column 13 of the <br />Inventory Reconciliation Sheet) <br />List date# tack 1, and smunt for all variations that exceeded the <br />allowable lis:its. <br />Date <br />1. <br />2. <br />3. <br />4. <br />5. <br />Tank E Amount <br />Additional dateslr uotz shall be continued on a ec;:arate cion -at of <br />paper and attached. <br />It the source of the variation which.exceeded allowable lieits vas due to <br />a leak the incident shall be reported to S,J.L.H.D. Environm;nt:,l Ucalth <br />Within 24 hours and an unauthorized release report submitted. <br />The quarterly suomary report ah --11 be submitted within 15 days of the end of each <br />quarter. <br />I - January March /�� b <br />Q�acter 2 - April --> June <br />July --) Scpccmhcr <br />Quarter 4 - October --> December <br />Send to: SAN JOAQUIN LOCAL HEALTH DISTRICT <br />1601 E. Hazc1L::11, P.O. Box 1009 <br />SLockcon, CA 95101 466-6761 <br />T 40 LO/B6 <br />