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~✓ <br />INVENTORY RECONCILIATION <br />QUARTERLY SUMMARY REPORI FORM <br />F.eility Name:/-�),� _1-7> <br />Facility Addreaa: ,r2 C? r,(JJvctiRf <br />Telephone: tz/„y7_ e py <br />Person Filing <br />Reporc 11 �7 �i4L/7/da✓D9 <br />OCT 1 ;nes <br />ENVIRONMENTAL HEALTH <br />PERMIT/SEnVlccc <br />U-,�I hereby certify under penalty of perjury that all inventory variations for <br />the above mcncioncd faciliCy were within the allowable Limit■ for this <br />quarter. (No in Column 13of Chc lovcacory Reconciliation sheet:) <br />ElInventory variations exceeded the allowable Limits for this quarter. L <br />hereby certify under pcnalCy of perjury than the source for the variation <br />was GOC due Co as unauthorised (leak) rel"ae. (Yes in Colum 13 of the <br />Inventory Reconciliation Sheet) <br />List date,i•task f, and amount for all variations that exceeded the <br />allowable l=i mita. <br />D2 cc 4:,, •- Tank / Amouoc <br />i <br />1. <br />2_ <br />3. <br />4. <br />5. <br />Addicioaal dates/amouacs shall be concioued on a separate sheet of <br />Paper and attached. <br />!f Che source of the variation which exceeded 'allowable Limits was du} to <br />a leak Chc.ine idenc shall be reported Cn S, J .L,H.D. FnviroamcncaL ilcalch <br />within 24 hours and an unauchorizcd.: relcate report submitted. <br />The Quarterly su — ry report shall be submitted within 15 days of the end of caph <br />quarter, <br />-QuarC••r I - Janwwry --) M.irch <br />Q•iarcer 2 - Apri l <br />Q( arCrtr ) - July __) ]c ptCmh.•r <br />Q•u rCcr 4 - occobcr --> Oecr.her <br />Scnd Co: SAN JOAQU I N LOCAL HEA1.1-Ii D I S'I'R I M <br />1401 L:. I!azt•II ul, 1'.0. Rox 20119 <br />5tockcon, CA '15201 466-67bl <br />•0 In/N4 <br />