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PETERS ENTF-'0Ri"` <br /> P.O. BOX,�r3,g <br /> FRENCH CAMP,1�4k ORY RECONCILIATION <br /> QUARTERLY SUMMARY REPORT FORM <br /> Facility Namei �'_ F«� tiZ AFF �v Tank / <br /> Site Product <br /> Facility Addreaat �j \ <br /> r <br /> Telephone : <br /> Person ming <br /> Report <br /> ❑ L 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 is Column 13 of the Inventory Reconciliation Sheet) <br />? Inventory varistioas exceeded the allowable Limits for this quarter. L <br /> hereby certify under penalty of perjury that the source for the variation <br /> was not due to as unauthorized (leak) release. (Yes is Colum 13 of the <br /> Inventory Reconciliation Sheet) r <br /> List date. cask /, and Amount for all variations that exceeded the <br /> allowable limics. ` <br /> Date Tank I <br /> Amount <br /> t. <br /> 4. <br /> 5. <br /> Additional dates/amounts ,hall be continued on ■ aeparate sheet of <br /> paper and attached. <br /> If (he source of Che variation v111eh c.cecdcd alluwble limits w s due to <br /> • leak the inciden( shall be rcpor(cJ c ) S . J 1- . H . D . Environmental Ilcalth <br /> vschin 24 hours and an unauCho n [ed release report submitted. <br /> Q'.r quarterly summary report shall be rcubmiCCed vith ,n 1S days of the end of each <br /> Quarter I - January <br /> Q•aartcr 2 - April --> J.", <br /> Quarter 3 - July __) icp(cmhrr <br /> Q•urtcr 0 - Octobcr --) Il�ccmhcr <br /> S<nd Co: SAN JOAQU IN LOCAL HEALI'li U 1 STH 1 Cf <br /> 1601 G . 1:.�7.t• Il ul , 1• . 0 Itis )0117 <br /> III;T 2.0 I0/ 86 <br /> Stockton . CA 75201 466 - 67bl <br /> � <br />