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4 <br />R 'EIVED <br />EC <br />JUL 2 3 1990 <br />INYENTORY RECONCILIATIOK NVIR N M ENTAL HEALTH <br />QUARTER Y SUMMARY REPORT FORM PERMIT/SERVICES <br />Facility Name Tank 1 Site Product <br />/011 <br />Facility Address: r <br />Telephone: <br />Person Filin <br />Report <br />L hereby ccrCify 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 Colum= 13of the Inventory Reconciliation Sheet) <br />Qinventory variations exceeded the allowable limits for this quarter. I <br />Hereby certify under penalty of perjury Chat the source for the variation <br />was not due Co an unauthorized (leak) release. (Yes in Column l3 of the <br />LavenCory Reconciliation Shecc) <br />Last date. tank 1, and amount for all variations Chat exceeded the <br />allowable lis+ita. <br />Date Tank I Amount <br />t_ <br />3. <br />4. <br />5_ <br />Additional daces/:mounts shall be contioued on s separate sheet of <br />paper and actached. <br />If the source of clic 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 sucasary report shall be submitted vichin 15 days of the end of Cacti <br />quartCr- <br />Quartor I - January __) Harclt <br />Q`larter 1 Aprl l <br />Qvar(rr ) - July <br />Q'Aarter 4 - October <br />Send co: SAN JOAQU I N LOCAL HEALTH DISTRICT <br />1001 E'. 1'.0. Rw( <br />SLockcon. CA 115201 466-67bl <br />"0 10/86 <br />I <br />