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. JENTORY RECONCILIATION <br /> QUARTERLY SUMMARY REPORT FORM <br /> '�ly� ��yIZKIz-� Bit <br /> Facility Name: ��Facility Address : <br /> cnn,av e4 • g SZ ZD <br /> Telephone: � 5 q 3 3-`i 3 G C, — <br /> Person Filing <br /> Report: 'e n `L� I l C ✓2 U <br /> 0 I hereby eartify 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 Colum 13 of the Inventory Reconciliation Sheet) <br /> 9 <br /> f <br /> Imventory, vaciatibas exceeded the allowable limits for this quarter. ' I <br /> hereby certify under penalty of perjury that the source for the variation <br /> was sac due to as unauthorized (leak) releise. (Yys in Column 13 of the <br /> Inventory Reconciliation Sheec) <br /> List data. tank to and aaxwnt for all variations that exceeded W6 <br /> allowable limies. Tnk Amount C C Itl <br /> E <br /> Date <br /> J U L 12 109% <br /> y, �z�_ v � VIRONMENTAL HEALTH <br /> 3 • JS' /7 # "i�D PERMIT/JER1r:Oc <br /> 5. <br /> 6, <br /> 7. <br /> 9. 9.t/-2 5 <br /> 10. d/ _ <br /> 11. <br /> 12. <br /> 13. <br /> 14. <br /> 16. A� <br /> 17. <br /> 18.x_ <br /> 19. <br /> 20.x_ <br /> 21. <br /> 22.x_ <br /> 23.x_ <br /> 24._x_ <br /> 25. <br /> 26. <br /> 27. <br /> 28. <br /> 29. <br /> 30. <br /> 31.x_ <br /> Additional dates/a.ouotx shall be_eoatimued on a separate sheat of <br /> paper and attached. <br /> If the source of the variation which.exceeded al'lowablelis wasdue to <br /> a task the incident shall be reported to S.J .L.H.D. Environmental <br /> alch <br /> within 24 hours and an unauthorized release report submitted. <br /> Tba quarterly susnacy report &hall be submitted within 15 days of the and of each <br /> quarter. <br /> Quarter 1 - January --> March <br /> Quarter 2 - April June <br /> Quarter ) - July --> Septemhor <br /> Quarter 4 — October --> Dccember <br /> Seed to: SAN JOAQUIN LOCAL HEALTH DIS'l'H1CT <br /> 1601 E. IlazOIC4,11 . p .0. jinx 2009 <br /> . Stockton . CA 95201 466-6761 <br /> T 40 10/86 <br />