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61"VE14TORY RECO116L IAT ION <br />QUARTERLY SUMMARY REPORT FORM <br />Facility Name: )n .9 r C .lark- "'3 <br />facility Address: 943 Ir )*6ir—e <br />'Felephone : Yy�--o20s/ <br />Person Filing <br />Report " t <br />Tank / Size <br />/Il,� W— <br />Product <br />to <br />d <br />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 13of the Inventory Reconciliation Sheet) <br />El inventory variations exceeded the Allowable limits for this quarter. I <br />hereby certify under penalty of perjury that tlae source for tlee vnrintion <br />was not due td nn eanruthorized (leak) release. (Yes in Column 13 of the± <br />Inventory Reconciliation Sheet) <br />Lint date, tank 1, and Amount for all variations tha led the <br />allowable limits. <br />Date Tank / Amount n <br />�0 � <br />a <br />2. <br />d <br />4. y. <br />S. <br />e � <br />Additional datr_s/»mounts shall be continued on a separate khect of <br />paper and attached. <br />If tlee sourct. of the variation which exceeded allowable limits "An dur. to <br />a leak the incident slentl be reported to S.J.1,11.U. Environceeeltnt Ileatth <br />within 24 hours and an unauthorized release report submitted. <br />'aIle quarterly summary report shall be nubmitted within IS days nl tier, end of r_:ach <br />quarter. , <br />ttuarter 1 - Jantaary --> Narcle <br />traarter 2 - April <br />.felly '°•—, SepteM114!r <br />�irrtcr 4 - October -->December <br />Send to! SAN JOAQU LN LOCAL HEAL; l'11 <br />16U 1 E. 11.nze 1.Loti , P.O. BOX 2009 <br />SLOCkLoll, CA 95201. 466-6781 <br />UG'I' 40 10/86 <br />