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INVENTORY RECONCILIATION <br />QUARTERLY SUMMARY REPORT FORM <br />raeLLLty Name: Cp[/Forzrw79 N/Cl%GUA / P14TX�OL <br />racilicr,Address: 3g5 -W, 0i2A&r;r- /6 RD <br />7R 4 C Y C 953 76 <br />Telephone: 269 - 83 ti - 8 9?b <br />Person Filing <br />Report 915nVNN7)V LU. YY7/1,L./0i9n) <br />LJ <br />Tank 1 Size Product <br />'/ OD L UNL F C <br />BI hereby certify under penalty of perjury that all inventory variations for <br />the above mentioned facility were within chc allowable limits for this <br />Quarter. (No in Coluwn 13of the Inventory Rc--onciliation Sheet) <br />0 Inventory variations exceeded the allowable limits for this Quarter. I <br />hereby certify under penalty of perjury that the source for the variation <br />vas not due to an unauthorized (leak) relelse. (Yes in Column 13 of the <br />Inventory Reconciliation Sheet) <br />List date, tank 1, and amount for all variations that exceeded the <br />allowable limits. <br />Date Tank 1 Amount E <br />1- /-/3-85 266-1 p <br />, <br />z. 1 <br />4. j <br />5. <br />Additional dates/a unts shall be continued on a separate sheet of <br />paper and attached. <br />If the source of the variation, which. 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 unauthorixcd release report submitted. <br />The Quarterly sum, ry report shall be submitted within 15 days of the end of each <br />Quarter. <br />Quarter 1 - January --) March <br />Quarter 2 - April --> June1 W'• .1111- <br />Quarter 3 - July --) September f'), j,�l�9d�] <br />Quarter 4 - October --) December P VVV <br />Send to: SAN JOAQUIN LOCAL HEALTH D1S'CH1C1' JAN 1 <br />160 L E. Haze I Lon , P .0 lids 2009 ENVIROMENTAL HEALTH <br />Stockton, CA 95201 466-6781 PERMIT/SERVICES <br />UCT 40 10/86 <br />i <br />> <br />