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INVENTORY RECONCILIATION <br />QUARTERLY SUMMARY REPORT FORM <br />Facility Name: �2AaJKs �A1E ST, -„o Fao,D AIA4T <br />Facility Address: aqD Al. MA /A,/ ST. <br />A AI TEP_ A P A <br />Telephone: c-.),3 9 - � Ll V (n _ <br />PersonTo <br />ing <br />Report A 6�_p <br />0 1 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 />� <br />�j 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 t <br />allowable limits.' <br />Date Tank Amount APR 1 3 •'�� <br />_84, ENVIRONMENTAL HEALTH <br />PERMIT/SERVICES <br />2. 1-5 -90 3 <br />3. 1 -fin -ciD- 3 <br />4. 1--;)n --qa .3 <br />5.. 1 -'10 <br />Additional dates/amounts shall be continued on a separate sheet of <br />paper and attached. <br />If the source of the variation which exceeded allowable 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 end of each <br />• quarter. <br />Quarter 1 - January --> March <br />Quarter 2 - April --> June <br />Quarter 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 />UGT 40 10/86 <br />