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IN•NTORY RECONCILIATION <br /> QUARTERLY SUMMARY REPORT FORM <br /> Facility Name: �T0 �oelur �Pqq o <br /> Tank Size Product <br /> racLILCrAddreas: 7y>,3 Cct�.;s /�.,: ' 3' <br /> qac? <br /> Telephone : <br /> Person Filing <br /> Report <br /> hereby Certify under penalty of perjury thatall inventory rar'e <br /> ti <br /> the above mentioned facility were within the allowable limits forthiss for <br /> quarter- (Ko in Column U of the lnventocy Reconciliation Sheet) <br /> ❑ Inventory variations exceeded the allowable limits for this quarter. I <br /> beceby certify under penalty of perjury that the source for the variation <br /> was not due to as unauthorised (leak) releise- (Y_s in Column 11 of the <br /> Inventory Reconciliation Sheet) <br /> List data@ tank to and amount for all variations that exceeded the <br /> allowable limits. It g„s�. <br /> Date task / Amount C V C <br /> i- APR 1 1 10NR <br /> 2- ENVIRONMENTAL HEALTH <br /> 3- PERMIT/SERVICES <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 anunauthorised release report submitted. <br /> the quarterly summary report shall be submitted within 15 days of the end of each <br /> quarter. <br /> Quarter I - January --) March <br /> Quarter 2 - April --) June <br /> Quarter 1 - July __> September <br /> Quarter 4 - October .-> December <br /> Send to: SAN JOAQUIN LOCAL HEAL1'li DIS'rkic1' <br /> 1601 E. Hazeltoai , P .O. Bo:c 1007 <br /> :T 40 l0/KG Stockton , CA 95201 466-67b1 <br /> x <br />