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4b <br /> JAN 9 <br /> INVENTORY RECONCILIATION ENVIRONMENTAL HEALTH <br /> QUARTERLY SUMMARY REPORT FORM P E R P4 I T IS E R V I C E S <br /> Facility Name: �--2- Tank I Size - Product <br /> I <br /> Facility Address: s2L' 1A-�tlz 7, <br /> �,CVI-,-4 , <br /> Telephone : t1c,--i'- 3-y <br /> Person Fi ing <br /> Reporto , 4 <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 /> quarter. (No in Column 13 of the inventory Reconciliation Sheet) <br /> DInventory 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 Nnauthorized (leak) release. (Yes in Column 13 of the <br /> Inventory Reconciliation Sheet) <br /> List date, tank 1, and amount for all variations that exceeded the <br /> allowable limits. <br /> Date Tank # Amount <br /> 1. <br /> 2. <br /> 3. <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 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 Harch <br /> Quarter 2 - April Julie <br /> Quarter 3 - July Septemher <br /> Quarter 4 - October December <br /> Send to: SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 L . Hazelton , P . O . Box 2009 <br /> Stockton , CA 95201 466-6781 <br /> !'GT 40 10/ 86 <br />