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APR 2 0 1992 <br /> INVENTORY RECONCILIATION ENVIRONIVIENTALHEALTH <br /> QUARTERLY SUMMARY REPORT FORM PERMIT/SERVICES <br /> racility Name: [°Ae,[ Ar ,E./1 TanA- Size ProductFacilit Address: E`r � -H1'Etco� Rv� � <br /> Mlhyi.FGf9, GA 9s�36 <br /> Telephone : _ 2p - 3- 9-�2S/ <br /> Person Filing <br /> Report ,8,//IWiL07>9 <br /> ® I hereby certify under penalty of perjury that all inventory variations for <br /> the above mentioned facility wre within rhefir-t1 K,S�- linin ' <br /> Lala= <br /> quarter. (No in Column I7of the Inventory 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 cot due to so unauthorized (leak) releise. (Yes in Column 13 of the <br /> Inventory Reconciliation Sheet) <br /> List date, tank /, and amount for all variations that exceeded the <br /> allowable limits. <br /> Date Tack / Amount <br /> 1. <br /> �2. <br /> /�/0mok� 7. <br /> 4. <br /> 5. <br /> Additional dates/amo,,o" s"'! bt co6t7—ed on a separate sheet of <br /> paper and attached. <br /> If the source of the variation whichexceeded allowable limits was due to <br /> a leak the incident _hall be repccted to S .J . L . H . D. Environmental licalth <br /> within 24 hours and an unax.thorizedrelcase report submitted. <br /> The quarterly summary report shall be submitted within 15 days of the end of each <br /> ouarter. <br /> �Quartcr1 - _ January_,-_-) March . <br /> Qlarter 2 - April —) June <br /> Quarter ) - July --) Septemher <br /> Quarter 4 - October --) December <br /> Send to: SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E . Hazelton , P .O . Box 2009 <br /> 40 10/86 Stockton . CA 95201 466-6751 <br />