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Ir 6 t t,4 4"r <br /> INVENTORY RECONCILIATION <br /> // <br /> QUARTERLY SUMMARY RfPORT FORM <br /> Facility Nage; Z l fVO4k, Tank f Size Product <br /> Facility Address: Qp ; <br /> 00 ?e S <br /> Telephone : 2Qy • / c <br /> Person Fililt��-�� <br /> Report aw, 6�� ir'ztJ <br /> 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 I7of the inventory Reconciliation Sheet) <br /> Inventory variations exceeded the allowable limits for this quarter. I <br /> hereby certify wader penalty of perjury that the source for the variation <br /> was not due to an uosuthorixed (leak) release. (Yes in Column 13 of the <br /> Inventory Reconciliation Sheet) <br /> List date, tack f, and amount for all variations that exceeded the <br /> allowable limits. <br /> Date Tank f Amount <br /> 1. <br /> 2. <br /> J. <br /> 4. <br /> S. <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 . .) . L . H . D . Environmental Ilcalth <br /> 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 /> x <br /> Quarter I - January --) March /S <br /> Quartr I - April --) Jun'- of <br /> Quarter 7 - July __) September 0 <br /> Q.arter 4 - Octobertcmber �\ <br /> Send to: SAN JOAQUIN I.00AI. HEAL-1-1i DISHM:] MAR 201999* <br /> 1001 H. I!:,zell .m , 1' 0 h''.: 7HW <br /> titockton . CA 95201 /.r,,, blhl ENVIRONMENTALHEA.TH <br /> 111/ 80 <br /> PERMIT/SERVICES <br />