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OCT 2 3 1989 <br />ENV � • <br />(ppRONIMENTAL HEALTH --IDiL Q(.4AoPe419-9%3 <br />INYENTORY RERfttC`I'�''i`aTVt�C5 <br />r <br />a <br />QUARTERLY SUMMARY REPORT <br />Facility ?tare • <br />Facility Address: <br />Telephone: G'jC�g_ <br />Person Fng <br />Report fJ..�J r`�, �,,,•� <br />size —L—'dur <br />I hereby certify under penalty of perjury th_t ell 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 />ElInventory variations exceeded the allowable limits for this quarter. I <br />hereby certify under penalty of�perjury that the source for the variation <br />vas not due to an unauthorized (leak) relcise. (Yes in Column 13 of the <br />Inventory Reconciliation Sheet) <br />List date, tank I, and amount for all variationz that exceeded the <br />allowable limits_ <br />Date Tank f Amount <br />1_ <br />2. <br />3. <br />4. <br />S_ <br />Additional dates/amounts shall be continued on a reparate sheet of <br />paper and attached. <br />If the source of the variation which.excecded at-lowable limits was .due to <br />a leak the incident shall be reported to S.J.L.H.D. Environmental licalth <br />WILChin 24 hours and an unauthorized release report submitted. <br />The Quarterly summary report shall be submitted vithin 15 days of the end of each <br />quarter - <br />Quarter i <br />- January <br />Harch <br />QQiartcr 2 <br />- April --> <br />June <br />Quarter 3 <br />- July --> <br />Septemhvr <br />Q'.arter 4 <br />- October---> <br />--ik:cember <br />Send to: SAN JOAQUIN LOCAL HEALTH U1STRICT <br />1601 E. E'.aze l i tin . P .O . 1iox 2OO') <br />40 10/86 SLockron. CA 05201 466-67b1 <br />14 <br />