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INVENTORY RECONCILIATION <br />QUARTERLY SUMMARY REPORT FORM <br />Fa 'I• 2 <br />y :a <br />k t* <br />J U L 2 2^'?1 <br />ENVIRONMENTAL H17ALTH <br />PERMIT/SERVICES <br />ci ity Name: o ee% �IcCoyb C�2vw,ci Tank i Sire <br />Product <br />Facility Address: loo1-U S///Ig, <br />o o e- � 4 . <br />5�5�4 P61 ` <br />Telephone: 109_ <br />Person Filing / <br />Report . /Ile <br />��r = ®�� <br />(�Q 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 />LJ 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) releise. (Yes in Column 13 of the <br />Inventory Reconciliation Sheet) <br />I <br />List date, tank i, and amount for all variations that exceeded the <br />allowable limits. <br />Date Tank f Amount <br />2. <br />3. <br />4. <br />S. <br />Additional dates/amounts shall be continued on a separate sheet of <br />paper and attached. <br />TF .`.c ai;u.-ce of tiie variation whichexceeded 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 --1 Harch <br />Q`jarter 2 - April --> June <br />Quarter 3 - July --> Septemher <br />Quarter 4 - October --) Oc-cember <br />Send to: SAN JOAQUIN 1.() AI. HEALI'li UISTHICT <br />160 1 E. Hazv I i on , I' . 0. liox 200g <br />Stockton, CA 95201 466-6781 <br />Uc:T 40 10/86 <br />