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INVENTORY RECONCILIATION G APR Ile" 9aui <br /> QUAR:T.ERLY SUMMARY REPORT FORM rNYWOMEN?AL HEW" <br /> E ERMIT/SERVICES, <br /> Facility Names Re,-r Tank i Site Product <br /> 7776TY/ <br /> Facility Address: 7..�JZD' �/ 2/�f ��i 2 / 77 /E <br /> Telephone : 6f Z6i6 <br /> Person Filing <br /> Report STEGE iI �GL�'7 <br /> ElI 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 Jor 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 t, and amount for all variations that exceeded the <br /> allowable limits. <br /> Date Sank ! Amount <br /> 1. <br /> 2. <br /> 3. rz- 7 / /6 <br /> 4. 3- 7 / S6 <br /> 5. 3- 7 / 9 <br /> 6 3. 73 7 <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 1 - Jaauary --) March <br /> Quarter 2 - April --> June <br /> Quarter 3 - July --> September <br /> Quarter 4 - October --) December <br /> Send to: SAN JOAQUIN LOCAL HEA1.1.1i DISTRICT <br /> 1601 E . Flazellon . P .O . 11nx 2009 <br /> SLockton , CA 95201 466-67b1 <br /> UCT 40 10/ 86 <br />