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/ENTORY RECONCILIATION <br /> QUARTERLY SUMMARY REPORT FORM oaf, <br /> a1 m V1AA12.I�.r`�7 Facility Name: �� D �Facility Address: 4Z'�9 dh bc� hJ/Tele*ne:�t 3� a II -et -i t' LPerson Filing � �QReport: 6L <br /> IAY 2 5 l9^� <br /> I hereby certify under penalty of perjury that all inventory varia-iI�A NI'T'1ENTAL 'HEALTh <br /> the above mentiosed facility were within the allowable limits for t�'47 N11T/ ERVI E <br /> r <br /> quarter. (H_ is column 13of the Inventory Reconciliation Sheet) PE? C J <br /> Inventory variatibus exceeded the allowable limits for this quartan ' I <br /> hereby certify under penalty of perjury that the source for the variation <br /> was mot due to an unauthorized (leak) releise. (Yam in Coluaa 13 of the <br /> Inventory Recoaeiliatioa Sheet) <br /> r all variations that exceeded the <br /> List date, tank /o and anouat fo <br /> allowable limits. Amount <br /> Date Tank # <br /> I • 1 . .--- <br /> 2. I h l-7L � — qCl <br /> 3 .� <br /> 4 . <br /> S . 5 - 1 Y Z 07- - 1 -77 <br /> 6. - <br /> h 2 t (LL / - ( 47 <br /> 7. 11 — I1 4- 1,1 /- 4G <br /> 8. LZ"Z Ci `L <br /> 9._ MITI 3 r 3c7 / f 13 1 <br /> 10. -2q <br /> 11. ? G, - 3J 3 412.6 /- ( o ( <br /> 12. <br /> 13 <br /> 14.. / 2 <br /> 15. <br /> 16. tl- 2 G <br /> 17. Z <br /> — 340 / 25 S( <br /> Y <br /> 18. moi" 2 T— — T2 �- <br /> 19. E / -2 d- <br /> 20. <br /> 21._ fl// — _? Wl 7 T6 <br /> 22. /( -/7— - Z55 / � 2r/V <br /> 23. 7 / 2_7 <br /> 24. 2�i'3/ <br /> 25. 6 - 11 o <br /> 26.�3 �_ <br /> 27. /]�2'1 3 _ o / <br /> 28.__a, <br /> 29.--___- <br /> 30. <br /> 31.x_ <br /> Additioaa/ dates/aawuots shall be continued oo a separate sheet of <br /> paper and attached. <br /> If the source of the variation which- exceeded alltowabtt limitswas dueealth to <br /> a leak the incident shall be reported to S .J .L.H.D. <br /> environ within 24 hours and an unauthorized release report submitted. <br /> The quarterly summary report shall be submitted within IS days of the end of each <br /> quarter. <br /> Quarter I - January --> March <br /> Quarter 2 - April --)p June <br /> Quarter I - July September <br /> Quarter 4 - October December <br /> S401 to: SAN JOAQUIN LOCAL HEALTH DIS't'HICT <br /> 1601 E. Ilazelton . I' .0. Box 2009 <br /> . Stockton . CA 95201 466-6761 <br /> ;T 40 10/86 <br />