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Facility Name: C <br />of a <br />INVIWORY RECONCILIATION <br />QUARTERLY SUMMITRY RE=PORT FORM <br />�v11O-VA V"A T <br />Facility Address: -45 UJ Q'Q1Pk('0 <br />Telephone: t0 <br />Person Filing <br />Report: v►� <br />Size Product <br />5,00 At 3 C"-& . <br />I hereby certify under penalty of perjury that -all inventory variations <br />for the above mentioned facility were within the allowable limits for <br />this quarter. (No in Column 13 of the Inventory Reconciliation Sheet.) <br />Inventory variations exceeded the allowable limits for this quarter. I <br />hereby certify under penalty of perjury that the source for the varia- <br />tion was not due to unauthorized (leak) release. (Yes in Column 13 of <br />the Inventory Reconciliation 51-ject), <br />List date, tank #, and amount for all variations that exceeded <br />the allowable limits. <br />Date Tank # Amount . ,.. .. .5� .. ..». -,� <br />1. 1-1 - t So . i <br />2. 3-111 3 k OCT 2 ^� <br />3. 2-a — t '�_ b E NVIRO IENTAL HEALTH <br />4. 01 -6 t + go— PERMIT/SERVICES <br />5. 'l- ?S <br />Additional dates/amounts shall be continued on a separate sheet <br />paper and attached. <br />If the source of the variation which exceeded allowable limits was <br />due to a leak, the incident shall be reported to San Joaquin Local <br />Health District; Environmental Health Division, within twenty-four <br />(24) hours and an unauthorized release report submitted. <br />The quarterly summary report shall be submitted within fifteen (15) days <br />of the end of each quarter. <br />Quarter 1 -- January ---------- >March <br />Quarter 2 - April ------------ >June <br />Quarter 3 July ------------- >September <br />Quarter 4 - October ---------- >December <br />Send to: SAN JOAQUIN LOCAL HEALTH DISTRICT <br />1601 E. Hazelton, P.O. Box 2009 <br />Stockton, CA 95201 468-3420 <br />LII 23 019 10/86 <br />