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�" pk� � T A „1� <br /> •�� R <br /> INVENTORY RECONCILIATION JAN 1 019?330 <br /> QUARTERLY SUMMARY REPORT FORM ENVIRCINIVIrNTALHEALTH <br /> PLER1%i ,, v'I:-RUl,-':.=3 <br /> Facility Name: tp�l� Tank � size Product <br /> //'- / ,,�/ A0006 a so <br /> Facility Address: 5765 /)Y , /� g C�. <br /> 07`l�e[a a cl ?n6 <br /> Telephone : �DCf <br /> Person Filing <br /> Report 1P � .� Wolemskl - <br /> 1 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. (Ho in Column 13 of the Inventory Reconciliation Sheet) <br /> E9/"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 /> List date, tank #, and amount for all variations that exceeded the <br /> allowable limits. <br /> Date Tank # Amount <br /> t. /WI / bg 1 3g 2g, <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 --> June <br /> Quarter 3 - July --> September <br /> Quarter 4 October --> a December <br /> Send to: SAN TOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E . Hazelton , P .O . Brix 2009 <br /> Stockton , CA 95201 466-6781 <br /> UCT 40 10/ 86 <br />