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GO 0 C � n s : <br /> INVENTORY RECONCILIATION APR 15 <br /> QUARTERLY SUMMARY REPORT FORM ENVIRONMENTAL <br /> VIRONMENTAL HEALTH <br /> Facility Name: PERMIT/SERVI <br /> Tank I Size <br /> Product <br /> Facility Address: YX P0,8"X'r/ s2 <br /> U D cfused <br /> z �i 5 330 O <br /> Telephone : Z Z -,2 Z 7Q <br /> Person Piling <br /> Report _�CtIYGS lY! � 1ti <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 13 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 an unauthorized (leak) release. (Yes in Column 13 of the <br /> Inventory Reconciliation Sheet) <br /> i <br /> List date, tank 1, and amount for all variations that exceeded the <br /> allowable Limits. <br /> Date Tank f Amount <br /> I. <br /> 3. <br /> Additional dates/amounts shall be continued on a separate sheet of <br /> paper and attached. <br /> If the source of the variation whichexceeded 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 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 3 - July --) September <br /> Quarter 4 - October --> Ikcember <br /> Send to: SAN JOAQUIN LOCAL HEALTH D1S1kICT <br /> 1601 E . Hazeli.on , P . O . Box. 2009 <br /> UCT 40 10/ 86 Stockton , CA 95201 466 -6781 <br />