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�Icd I V 161 <br />td2 <br />INVENTORY RECONCILIATION JUL 111989 <br />1 I'ti <br />ly QUARTERLY SUMMARY REPORT FORM <br />';IENTAL H,rALiN <br />raciLLCy Hame: 09f.1FOR1I/I9 9101WXY 170MOC <br />Facility;Addrem a: 38s�whST CKr4Nrl/IVN" <br />r)?&eY C19 95376 <br />Telephone: 7-01 - 835- 89ZO <br />Person Filing <br />Report 414, M11LICIIN <br />Tank t Size Product <br />19 L hereby certify under penalty of perjury that ■I1 inventory variations for <br />the above saeacioned facility were within the allowable limits for this <br />quarter. (Ho is colu® 13 of the loventory Reconciliation Sheet) <br />E] Inventory variations exceeded the allowable limits for this quarter. I <br />hereby certify under penalty of perjury that the source for the variation <br />was not due to as unauthorized (leak) release. (Yea is Coln 13 of the <br />Inventory Reconciliation Sheet) <br />List date, tank 1, and anounc for all variatioas that exceeded the <br />allowable Limits. <br />Date Tank l <br />2. <br />3. <br />4. <br />5. <br />Anwun C <br />Additional dates/s ouata shall be continued on E eUrsrzte s7: et of <br />paper and actached. <br />If the source of the variation which exceeded allowable limits wan due to <br />A leak the incident shall be reported to S,J.L.H.D. Environmental Ucalth <br />within 24 hours and an unauthorized release report subuitted. <br />The quarterly su--,ry report shall be submitted within 15 days of the end of each <br />quarter. <br />Quarter I - January --) Harch <br />garter - April --> June <br />Irter - July --) Sepcember <br />Quarter 4 - October --> December <br />Send to: SAN JOAQUIN LOCAL HEALTH DISTRICT <br />160L E. HazelLoo. P.O. cos 2009 <br />SLockcon. CA 95201 466-6781 <br />T 40 IO/96 <br />6 <br />