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1 0 0 <br />INVENTORY RECOPdCILIATION <br />QUARTERLY SUMMARY RFPORT FORM <br />Facili[T Name• `t� t. <br />Fac. icy Address: a®� ► 9 <br />► <br />Telephone: <br />Person Filinn, --- <br />Report e <br />I hereby certify under penaltq of perjurythat e <br />ll invi <br />the above Mentioned facility were within the allowablecntory limi[svfora[hia$ for <br />Quarter. (No in Column 13 of the Inventory Reconciliation Sheet) <br />QInventory variations exceeded the allowable lice* for this <br />bereby certify under penaltyof for I <br />perjuy that was not due to an unauthorized (leak) <br />r <br />Inventory Reconciliation Sheet} relcaccCh(YeSuineCojr the variation <br />umn 13 of the <br />List date, tank 1, and amount for all vaci <br />allowable limits. a[ioas that exceeded the <br />Date Tank P <br />t4,1aO 11 n C <br />I. <br />2_ RECEIVED <br />-- — -- __ <br />3. APR 15 i9gi <br />4. ENVIRONMENTAL HEALTH <br />5. PERMIT/SERVICES <br />Additional dates/amouocs shall be continued on a <br />Paper and at Cached. separate sheet of <br />If Che 'source of the variation which exceeded allowable lim <br />a leak the incident shall be reported to its was due to <br />within 24 hours and an unauthocir.cd rrlr_,'ss'J.L.1I.1). Environmental 11calth <br />report st,t).,'Placd. <br />The terdy sucuxa7ry re�Doet shall G<r sub n <br />Quarcre*-r etted within IS days (It the endof <br />, <br />QUJrCer I - Januncy --) tlarch <br />arrer 2 - Abri 1 --> Jun,• <br />Quarter 3 — July --� :eC(DCa rnhr:r <br />Quarter 1e - OCt0ber --) 1h` <br />Ccmblr <br />r <br />.end <br />to: ;AN .JOAQUIN LOCAL. HEAL'I'!! <br />1601 F. liaze l ton , p.0 I3c)x 1009 <br />LICT 40I0/86 Stockton, CA 95201 466_6781 <br />