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• 40YVEMI <br /> INVENTORY RECONCILIATION DEC 14 1987 <br /> • QUARTERLY SUMMARY REPORT FORM ENVIRUMEvTAL HEALTH <br /> PERMIT/SERVICES <br /> Facility Name:�jRyT- � v/, r rank / Siteroduct <br /> /000 <br /> Facility Address. <br /> S ra/.Y ro.c.J <br /> Telephone : <br /> Person Fi ng^ <br /> Re p o r <br /> L hereby certify under penalty of perjury Chat all inventory variations for <br /> the above mentioned facility were within the allowable limits for this <br /> Quarter. (No in column 13 of the Loveatory Reconciliation Sheet) <br /> ElInventory 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 as unauthorized (leak) releise. (Yes in Column 13 of the <br /> Inventory Reconciliation Sheet) <br /> List date. tank /, and amount for all variations that exceeded the <br /> allowable limits. <br /> • Date rank 1 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 /> Lf 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 Rubmicced within 15 days of the end of each <br /> Quarter. <br /> Quarter 1 - January --) Harch <br /> Quarter 2 - April --> June <br /> Quarter 3 - July --) September <br /> Quarter 4 - October --) 1k comber <br /> Send to: SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> • 160L K . i!aze l t on . P .O . lion 2009 <br /> Stockton . CA 95201 466 -6761 <br /> UCT 40 10/86 <br />