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I OWENTORY RECONCILIATION <br />QUARTERLY SUMMARY REPORT FORM <br />Facility Name: a11'uAnn IRM 1DES_ <br />5A�71LE iIi'd <br />Facility Address: p".ACE <br />INTERSTATE 5 & 111WAY L4 <br />Telephone: LOD ' ;' r ` <br />Person Filing-�?.e-'•�e��5 <br />Report <br />OCT 2 7 1989 <br />ENVIRONMENTAL HEALTH <br />PERMIT/SERVICES <br />Tank # <br />size Product <br />fy,r- <br />0 <br />I hereby certify under penalty of perjury that all inventory variations for <br />the above mentioned facility were within the allowable limits for this <br />quarter. (No in column 13 of the Inventory Reconciliation Sheet) <br />C] 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 an unauthorized (leak) release. (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 Tank # Amount <br />2. <br />3. <br />4. <br />S. <br />Additional dates/aMouots shall be continued on a separate sheet of <br />paper and attached. <br />If the source of the variation which exceeded &Plowable 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 unauthorized release report submitted. <br />The quarterly summary report shall be submitted within 15 days of the cad of each <br />- quarter. <br />Quarter I - January --> March <br />Quarter 2 - April --> June <br />arter 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 466-6781 <br />UCT 40 10/86 <br />