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INYENTO�Y RECONCILIATION <br />QUARTERLY SUMMARY REPORT FORM <br />Facility Name: <br />Fscitity�Addreaa: (6v9� ��,,,�y,..`, <br />Telephone: qfj ,rs ori <br />Person Filing <br />Report c;Z�,_ �a <br />H'i E C L'ni O.V" <br />k;i' ' <br />0 CT 1 9 1GQ0 <br />ENVIRONMENTAL HEALTH <br />PERMIT/SERVICES <br />Tank f Site Prcduct <br />Gam,, <br />EjI hereby certify under penal y of periury that all inventory variations fer <br />the above mentioned facility were within the allowable limits for this <br />quarter. (No in Column l3 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 variation <br />was not due to an unauthorized (leak) release. (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 <br />t. <br />7//3 <br />2• 7/2 <br />3. �-/9 <br />4- a <br />5_ <br />Tank f <br />Amount <br />z <br />iv7 <br />z <br />neo <br />z <br />10,3 <br />Additional dates/amouats shall be continued on a separate sheet of <br />paper and attached. <br />If the source of the variation which. exceeded at -lovable limits was due to <br />it leak the incident shall be reported to S . J . L . H . D . Environmental lira 1 th <br />within 24 hours and an unauthorized release report submitted. <br />Itic quarterly summary report shall be Kubmitted within 15 days of the end of each <br />quarter_ <br />Quarter 1 - January --) March <br />Quarter 2 - April --) June <br />Quarter 3 - July --> Septcmhrr <br />Quarter 4 - October --) December <br />Send to: SAN JOAQUIN LOCAL HEALTH DISTEIICI' <br />1601 E. liaze l l un . P.O. Box 200" <br />Stockton, CA 95201 466-6781 <br />EH 23 019 10/86 <br />