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INVENTORY RECONCILIATION SEP 2 4 1987 <br /> QUARTERLY SUMMARY REPORT FORM pLtN ENVIROMENTAL HEALTH <br /> ES FERMIT/SERVICES <br /> Facility Name: _�� �- Tank Size Product <br /> Facility Address: jTT <br /> Telephone : 0142 - 277/ <br /> Person Fig <br /> Report /r,.� �u � � �r ; <br /> 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. (Ne is 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 /> was not due to an unauthorized (leak) releise. (Yes in Column 13 of the <br /> Inventory Reconciliation Sheet) <br /> List date, tank f, and amount for all variations that exceeded the <br /> allowable limits. <br /> Date Tank I Amount <br /> 1. <br /> 2. <br /> 3. <br /> 4. <br /> 5. <br /> Additional dates/amounts shall be continued on a separate sheet of <br /> paper and attached. <br /> If the source of the 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 I$ days of the end of each <br /> quarter_ <br /> Quarter I - January --> March <br /> Quarter 2 - April --> June <br /> Quarter 3 - July --) September : <br /> Quarter 4 - October --) December <br /> Send to: SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E . liaze1tlui . 11 . 0 . Box 2009 <br /> Stockton . CA 95201 466-6781 <br /> UGT 40 10/86 f <br />