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9INYENTORY R 9 <br />RECONCILIATION <br />QUARTERLY SUMMARY REPORT FORM <br />Facility Name: 4?uA, /T '7 W Tank / <br />Fac icy Address: 1030 Z <br />Telephone: Z- <br />Person Filing <br />Report /%4t ,IK X.'y <br />Size <br />Product <br />Ly <br />4z <br />a �� <br />cines <br />ICI 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 Column 13 of the Inventory Reconciliation Sheet) <br />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 i, and amount for all variations that exceeded the <br />allowable limits. <br />Date Tank I Amount <br />2- MAY 01 1989 <br />3. <br />4. <br />5. <br />ENV00"11'VI_NTAL HEALTH <br />PERMI' / SERVICES <br />Additional dates/amouats 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 I - January --) March <br />Quarter 2 - April --> June <br />r - July --> September <br />Q,actec 4 - October --> December <br />Send to: SAN JOAQUIN LOCAL HEALTH DISTRICT <br />1601 E. Hazelton, P.O. Box 2009 <br />IICT 40 10/86 Stockton, CA 95201 466-6781 <br />