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It1YEtITOQY RECONC IL IAT IOM <br />QUARTERLY SUMMARY REPORT FORM <br />EaciLicy Names <br />lacflity _rl,Qacs�ec <br />Telephone: <br />Person Min <br />Repor[ <br />Tank / Site Pcoduct <br />Q1 here y certify wader pemalCy of perjury chat all inventory variatioas for <br />the above mcaciomed facility were within the allowable Limits for this <br />Quactee. (No im Column I3of the lovencocy Reconciliation Sheet) <br />L xeatocy vaciatioas exceeded the allowable Limits for this quarter- L <br />beceby certify wader peaaLcy of perjury thaC Che source for the vaciaCioa <br />'+aa Cot due Co as uaauChocieed (leak) release. (Tet is Column ll of the <br />1—cacocy Reconciliation Sheec) i I 1 <br />List, date. Caak 1. aad amounc for all vaciaciooa chat exceeded the <br />allowable limica. <br />Dace Taak I AsOuaC <br />S. <br />Add le'LOCI •1 d4Ce1/aA&0uoCa Ch p be COnCioued oo . •<paCace •heeC of <br />paper and 3CCachcd. <br />It Che •ouCCC of Ct%C warl.2(ton-1•4ik ltmtC3 -.3% duc (o <br />• lc•k the inC►dcn( ahall be tcrurec•1 t!t `, I j {{ j) to+sconmcnC.2l Ilr�l(h <br />�kchsn z(. hours and an unr.thn.,r-1 t••1r.tt•• ret•nrt suba"'C". <br />i -11e Q.arCeelr aumzarr rc(+oCC shall be a•!b•.tl(�J vt(htn 1) days of Chc enJ of c.�Clt <br />QV a C C C f I - J a n u a f r - -) <br />Arr� l --> >�•., <br />Q-accec ) - July --> ic�te.n.•r <br />P••cccc c - occoec. <br />Send co: SAN JOAQU IN LOCAL HEALTI; l) 11l K lCl <br />160 i•- F. IV .0 Rt 13 /(ut') <br />Stockcon, r -A• -9520I 466-67bl <br />40 l0/80 <br />1•- � , <br />VOW <br />J �� �• ��r BMys :. .�t �lY'.J'ti•_�' <br />