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:.'1r <br />a � <br />L _ n-9n <br />INVENTORY RECONCILIATION <br />ENVIRONMENTAL HEALTH ,,.. <br />QUARTERLY SUNMARY REPORT FORM PERM FUSERVICES <br />FaciL ty H z :Flame- Li..qt oro Inc '� k i Siwe. Product <br />Facility ,'A dress s Baa x «� ci Rect <br />Unlead Prem <br />Telephone; <br />Person Filing <br />Report Pei.e Gragfignij <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 ColumnA3of the Inventory Reconciliation Sheet) <br />El 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. (You in Column 13 of the <br />Inventory Reconciliation Sheet) <br />List data, tank f, and amount for all variations chat exceeded the <br />allowable limits. <br />Date Tank f Amount <br />} a <br />y� 1 3 <br />4. <br />di.tional date uots :*hall be continued on a separate shut of <br />paper and attached. <br />If the source of the variation which -exceeded allowable limits was due, to i <br />a Leak the incident shall be reported to S.J.L. .D, Eavironmentat B alth <br />Within 24 hours sad an unauthorized release report submitted. <br />'rhe qu2rterly sucamary report shall be submitted within 15 days of the end of each <br />e�ea�rttwt'. <br />Quarter l - January Hareh <br />Q+A2rter x - Apti t .._, Juste <br />Quarter 3 _. July September <br />Quarter 4 october necember <br />Send to, SAN JOAQUIN LOCM, HEALTH DISTRICT <br />1601 E. glutze l c on 6 V-0, Rox 2009 <br />Stockton, CA 415201 466-6761 <br />(KA, 140 10/80 <br />