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a <br />INVENTORY RECONCILIATION <br />QUARTERLY SUMMARY REPORT FORM <br />Facility Name: <br />Facility Address; p7. -F- G5`. <br />Telephone:_ g 7Q 7 <br />Person Filing <br />Report <br />/J�G L GQ.�3Lft <br />APR 21^ D87 <br />ENVIROMENTAL HEALTH <br />FERMIT/SERVICES <br />Tank : <br />Size <br />lcc�co <br />Ac LOG <br />Product <br />UNG - J,Eyy, <br />2� ".6'a <br />N� <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 IJ 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 />List date, tank 1, mad amount for all variations that exceeded the <br />allowable limits. <br />Date Tank I Amount <br />Additional dateslamouats 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 />Qin rCer I - January --) Harch <br />Qiartrr 2 - April --) June <br />Q,arCer ) - July --) sep(ember <br />Qiartcr 4 - Oc(obrr --) 0,•c,•mber <br />Send to: SAN JOAQU I N LOCAL HEAI.I Ii W-11 1 r r <br />1 601 H. laza I t (ui . P 0 1t ';: MWJ <br />Stockton. CA (0201 1466-0/bl <br />