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• r1 to <br /> L7CEIVED <br /> INVENTORY RECONCILIATION SEP 3 0 1988 <br /> QUARTERLY SUMMARY REPORT FORM ENVIRONMENTAL HEALTH <br /> PERMaT/SERVICES <br /> Facility Names _FQ Roc ,i Tank I} Size Product <br /> IOdQ LS 77- <br /> Facility<Address: Lq)3 Loo, 5 AVE. -20dp p ;9s <br /> S —oc 77,JCA. 1.5-�05 4 Ire W . , o�L <br /> Telephone : 5 L4G , eo <br /> Person Filing <br /> Report <br /> E] 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 13 of 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) releise. (Yes in Column 13 of the <br /> Inventory Reconciliation Sheet) <br /> List date, tank i, and amount for all variations that exceeded the <br /> allowable Limits. <br /> Date Tank I Amount <br /> 1. <br /> 2. <br /> 3. <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 al'lowabte li=its was du: z to <br /> a leak the incident shall be reported to S .J .L.H . D. Environmental Health <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 /> Quarter I - January --) March <br /> Qu rter 2 - April --> June <br /> Quarter 3 - July --) September <br /> Quarter 4 - October --) December <br /> Send co: SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E . Hazelton , P . O . lion 2009 <br /> SLockron , CA 95201 466 -6781 <br /> UGT 40 10/ 86 r <br /> 1 <br />