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K(JPP�Z INVENTORY RECONCILIATION OCT 1 j 1988 <br /> 11 `,3 QUARTERLY SUMMARY REPORT FORM ; p.!TAL T!I <br /> Facility Name: !JQ/9 / � _ Tank I Site Product <br /> facility Addcess: � z�. z�fr�t) .f <br /> Telephone : <br /> Person Filing <br /> Report � �l J <br /> 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. (No in Column 1)of the Inventory Reconciliation Sheet) <br /> E] 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 as unauthorized (leek) release. (Yes in Colum® IJ of the <br /> Inventory Reconciliation Sheet) <br /> Gist date, tank 1, and amount for all variations that exceeded the <br /> allowable limits. <br /> Date Tank I Amount <br /> 1. <br /> 2. <br /> ]. <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 Health <br /> within 24 hours and an unauthorized retcase report submitted. <br /> The Quarterly summary report shall be submitted within 15 days of the end of each <br /> Quarter. <br /> Quarter I - January --) Harch <br /> Quarter 2 - April --) June <br /> Quarter 7 - July --) �cptcmhcc <br /> Quarter 4 ---0ctobcr --) flecomber ._ <br /> Send to: SAN JOAQUIN LOCAL HEALTH UISTKLCT <br /> 1601 K. Ilazc 11 4,n . V -0. Rtxx_.2009 <br /> Stockton . CA 95201 466-6761 <br /> UCT 40 10/86 <br />