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RECEINVENTORY RECONCILIATION I v ' <br /> QUARTERLY SUMMARY REPORT FORM MAY 4 1P717 <br /> ENVIRONMENTAL HEALTH <br /> > ��,� rr <br /> Facility Name���52��� i_L-t'li £NIC—�L�2'� Tank E !S —HV I( pduct <br /> GQ.aW 4 <br /> Facility Address; app/ RJ <br /> J�'lr1t Tyr C°i/�(iy <br /> Telephone : ��Iq _ I a3 -JIoJY <br /> Person Filing <br /> Report <br /> 1 <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. (No in Column 17of 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 for the variation <br /> was not due to an unauthorized ( leak) release. (Yes in Coles IJ of the <br /> Inventory Reconciliation Sheet) <br /> List date, tank 1, and amount for all variations that exceeded the <br /> allowable limits. <br /> Date Sank / Amount <br /> 1. <br /> 2. <br /> ]. <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 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 I - January --) .,rch <br /> r 1. Quarter 2 - April --S-June <br /> 7� Quarter J - July --) September <br /> Quarter 4 - October --> Ik:cember <br /> Send to: SAN JOAQUIN LOCAL HEALTH DIS'T'RICT <br /> 1601 E . 11,1ze I 1 (ui , 1' . 0 . Ros 2009 <br /> Stockton , CA 95201 466-6781 <br /> LI(;T 40 10/ 86 <br />