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�� \\\\\\]\✓` : liYi_'iTOPY :CCSC ' L : A; ; On <br /> QUARTERLY SUMMARY REPORT FORM <br /> Q< �c i 1A�WwAnheuser-Busch. Inc. Tank f Size Product <br /> - ` 1 I- n alp i n,o�oi <br /> FlaYy Address: 3932 Budweiser Court 2 OO r' als. ;asn n- <br /> �����°' -)toctcton, LauTornia 95205 I <br /> Telephone : (209? 931-5661 <br /> Person Filing <br /> Reporr Ron Mever <br /> ©X 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. (Ho in Column 13of 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 Column 13 of the <br /> Inventory Reconciliation Sheet) <br /> List date, tank t, and amount for all variations chat exceeded the <br /> allowable linits_ <br /> Date Tank f Amount <br /> 1. <br /> 2. <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 Hcalth <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 /> Qua rte�I�ativary --) March <br /> Quarter 2 - April --) Jvoc <br /> Quarter 3 - July --) September <br /> Quarter 4 - October --) Dkcember <br /> .'end to: SAN JOAQUIN LOCAL, HEALTH D1SCKICI' <br /> y 1601 L. 1!3zt• i tuuT • P . O . H()X 2009 <br /> Stockton . CA 95201 466 - 6781 <br /> �1 40 I0/ 86 <br />