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E 1 <br /> 73 , <br /> INVENTORY RECONCILIATION <br /> ENVPRONMEN T AL HELTH <br /> QUARTERLY SUMMARY REPORT FORM PERM IT/SLE-RVICE <br /> FaciLitr same; ,'Q r w'S r`Lk, Tank It Sire. Product <br /> El'scility�llddress: 9 <br /> j <br /> Telephone : �.. •, <br /> Person Filing <br /> Report <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 /> quartet'. (No in Columa 13 of the Inventory Reconciliation Sheet) <br /> Inventory variations exceeded the a llowable. timits for this quarter. Y <br /> hereby certify under penalty of perjury that the source for the variation <br /> -vas not due to an unauthorized (leak) cele ee. (Yes in Cohn 13 of the <br /> Inventory Reconciliation Sheet)' .— <br /> List date, tank 1, and amount for all variatioas that exceeded the <br /> allowable limita. <br /> Date Tank IE Amount . <br /> 1. • <br /> 3. <br /> 4. <br /> Additional daCes/amounci shall be continued on a separate sheet of <br /> paper and attached. <br /> if the -courcc .of the variation vhich. exc•ecded al-lovable limits was due to <br /> a leak the incident shill• be reported to S .J .L.H . D. Environmental Health <br /> within 34 hours and an unauthorized release report submitted. <br /> I <br /> The quarterly summary rc"rt shall be Rubmitccd within 15 days of the end of each <br /> quArter. <br /> Quarter 1 — Januar —) Har <br /> ch <br /> ch <br /> Jar _ <br /> Q' to 2 April --> ,lune <br /> Quartc_r - July --> SePtcmht.r <br /> Qu4—CC cr 4 October -> tkccmbcr <br /> Send to: SAN JOAQUIN I.UC:AL 1JEALTH DISTRICT <br /> 160I E. . HaXC 11c►11 , P .O . Box 2009 <br /> -Succkton . [.A X15'101 466-6781 <br /> T 40 L0/ HG <br /> f <br /> i <br />