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RECEIVED <br /> g""EyTORY RECONCILIATION JUL 17 1990 <br /> QUARTERLY SUMMARY REPORT FORM ENVIRONMENTAL HEALTH <br /> PERMIT/SERVICES <br /> Facility Name: 1 +A1 e7F7j�✓t� <br /> Tank Size <br /> Product <br /> Facility Address. 2, a uJ„Y <br /> /�, ct/92Tc�/C 2 orr o <br /> /tet /f9 OG MNL.Guly/iv�c <br /> Telephone : �,� 03�>�� <br /> Person Filing <br /> Re p o r t <br /> L hereby certify under penalty of perjury that all inventoryvaria <br /> ti <br /> 'he above mentioned facility were within the allowable lims forthiss for <br /> quarter. (No in Column 13of the Inventory Reconciliation Sheet) <br /> ElInventory variations exceeded the allowable limits for this Quarter. I <br /> hereby certify under penalty of perjury that the sour�;:e for the variation <br /> ws2 ort due CO an unauthorized (leak) release. (Yes in Column 13 of the <br /> Inventory Reconciliation Sheet) <br /> List date, tank f, and amount for 211 variations that exceeded the <br /> allowable lio,ics_ <br /> Date Tank Amount <br /> 1. <br /> 2. <br /> 3. <br /> 4. <br /> 5_ <br /> Additional dates/amounts shall be continued o❑ a separate sheet of <br /> paper and attached. <br /> i <br /> Lf the source of the variaziOn which exceeded allowable limits was due to <br /> a leak the incident shall be reported to S .J . L. H . p . Environmental 1lealth <br /> within 24 hours and an unauthorized release report submitted. <br /> The Quarterly summery report shall be Fubmitted within IS days of <br /> Quarter. the end of each <br /> Quarter 1 - January --) March <br /> (--QjarCcr 2 - Apri l --) u-—(14—!. <br /> Quarter ) - July --) Septcmb4*r <br /> Quarter 4 - october --) D,ct.wt?er <br /> Send to: SAN JOAQUtN LOCAL HEALTH DISTRICT <br /> 1601 E . 1!aze l t tin , 1' . 0 . 1tOx 2U( `) <br /> T 40 lO/ K6 St_ockcon , CA `15"201 400 -67b1 <br /> � <br />