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INVENTORY RECONCILIATION <br /> QUARTERLY SUMMARY REPORT FORM <br /> 4 <br /> Facility Mime; ,� e2Tank Size_ Product <br /> / 6 <br /> PacilitAddress: �^/ sfi/�G�e�J_ r'- <br /> �. <br /> Ic <br /> 7r .✓ �.gS ®/ . . <br /> Telephone :/ <br /> Person Filin <br /> Report <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 /> v °: W fi <br /> ElInventory variations exceeded the allowable limits For this quarttt�sr �a <br /> hereby certify under penalty of perjury that the source for the varis6t.tn1 5 19 <br /> $9 <br /> was not due to an unauthorized (leak) release. (Yes is Column 13 of the <br /> I»ventory Reconciliation Sheet) _NVIRONIMENTAL HEAT';'11 <br /> PERMIT/S `rte; 3 <br /> List date, tank r, and amount for all variations that exceeded the <br /> allowable iimics_ <br /> Date Tank 0 Amount <br /> z. <br /> 3. <br /> 4. <br /> Additional dates/=mounts 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 „1 ,L.H , p, Environmental Hcatch <br /> Within 24 hours and an unauthorized release report submitted. <br /> The quarterly summary report shall be submitted within IS days of the end of each <br /> quarter. <br /> Quarter I - January March <br /> Qh};rter 2 - April June <br /> --) Scpctcmhcr <br /> Quarter 4 - October --) Dccm era' <br /> Send to: SAN JOAQUIN LOCAL HEALTH Uis-rHICT <br /> 1601 E. liazelLoll , P .Q . lacy 2009 <br /> Stockton . CA 95.201 466-6761 <br /> LJGT 40 10/86 <br />