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l� I* <br />L l INVENTORY RECONCILIATION <br />QUARTERLY SUMMARY REPORT FORM <br />Facility Name: <br />Facility Address: <fn7j <br />7�iG'}C7 c � F(7r , <br />Telephone: <br />Person Filing— <br />Report <br />iling—Report <br />HEUI ED <br />10 OCT 2 3 1991 <br />ENVIRONMENTAL HEALTH <br />PERMIT/Si=RV, <br />Tank i Size Product <br />Z o oO� Lc <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 13of the inventory Reconciliation Sheet) <br />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 I, and amount for all variations that exceeded the <br />allowable limits. <br />Date Tank E Amount <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 Che 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 March <br />Quarter 2 - April --% June <br />Quarter J - July --> September <br />Q,ar octobcr --> Ge umber <br />Send cu,: SAN JOAQUIN LOCAL HEALTH [W;1RICI <br />1 601 E. 1lnzo I t tu, . P .O Its '. z0(P) <br />Stockton, CA (0201 46x, -07b1 <br />Uc;'I 40 10/80 <br />