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W <br />FaciLfty maw: / / -I t/ 1 a/ ,,ir` <br />! j <br />Address:,rte � F C r <br />i o.. .. <br />Person <br />Report . <br />(Em <br />r _ .► 9 r. i <br />0/00', 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 is Column 13 of the Inventory Reconciliation Sheet) <br />Inventory variations exceeded the allowable limits for this quarter. t <br />hereby certify under pecalty.of perjury that the source for the variation <br />was Got due to an unauthorized (leak) release. (Yes is Column 13 of the <br />Inventory Reconciliation Sheet) <br />List date, tank i, and amount for all variations that exceeded the <br />allowable Limits. <br />Date Tank 0 Amount <br />1. <br />2. <br />3. <br />4. <br />5. <br />Additional dates/amounts shall be continued on a separate sheet of <br />paper and attached. <br />Lf the source of the variation which. exceeded at-lowable 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 unauthorised release report submitted. <br />The quarterly summary report shall be submitted within 15 days of the end of each <br />quarter. <br />Quarter 1 - January --> March ! <br />Quarter 2 V=' April --) June (-1990) <br />Quarter 3 - July --> Septemher <br />Quarter 4 - October --' December <br />Send to: SAN JOAQU IN LOCAL HEALTU D I S1'K iCT <br />1601 £ . hazes 1 i on ° P.0. Box 2009 <br />Stockton. CA '/5201 466-6761 <br />.I(;1' 40 10/86 <br />