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FCE1 <br /> INVENTORY R+ECONC I F IAT 10H VED <br /> �'�� 0 2 1992 <br /> QUARTERLY SUMMARY REPORT FORM tF-"'RONMENT <br /> PERMir/�FpI/;HtA1,�'+ <br /> Facility Name: <br /> Tank I Size Produc t <br /> Facility -Address: A C� ��ev <br /> t 1N L <br /> Telephone : 0 <br /> Person Filing <br /> Report 77, <br /> rZI 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 columa 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 /> was not due to an unauthorized (leak) releise. (Yes in Column 13 of the <br /> Inventory Reconciliation Sheet) i <br /> List date, tank 1, and amount for all variations that exceeded the <br /> allowable limits_ <br /> Date Tank f Amount <br /> 1. <br /> 2. <br /> 3. <br /> 4. <br /> 5. <br /> Additional dates/amountx shall be continued on a separate sheet of <br /> paper and attached. <br /> If the source of the variation which. exceeded at-lovable limits was due to <br /> a leak the incident shall be reported to S ,] L. D . Environmental Ilea Ith <br /> within 24 hours and an unauthorized release report submitted. <br /> The quarterly sumaLary report shall be submitted within 15 days of the end of each <br /> quarter. <br /> Quarter I - January --) Harch <br /> Quarter Z - April --> June <br /> Quarter ) - July --) September <br /> Qtsartcr 4 - Octobcr tkcember <br /> Send to: SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 160L 1- , Hazc 1 t sin , 1' . Q . 1i()x 2()()'} <br /> `�tockton , CA X15201 466 -67b1 <br /> llt>T 4U L (7/ H6 <br />