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• <br />. INVENTORY RECONCILIATION <br />QUARTERLY SUMMARY REPORT FORM <br />Facility Name; <br />Facility Address; _/���� 4e: <br />cY� <br />Telephone: <br />Person Filing <br />Report <br />CEI VE D <br />J U L 15 1991 <br />ENVIRONMENTAL HEALTH <br />PERMIT/SERVICES <br />Tank / Size <br />Product <br />/ 11 x e_1 <br />cT�La sf <br />lnl I hereby cprt:ify under penalty of perjury that all inventory variations for <br />the above mentioned faciiity were within the allowable limits for this <br />quarter- (No in Coiumu 130' the inventory Reconciliation Sheet) <br />1 t Inventory variAtioas exceeded the allowable limits for this quarter. I <br />hereby certify under penalty of perjury that the source for the variation <br />V40 not due to as unauthorized (leak) release. (Yes in Columg IJ of the <br />Invegtory Reconciliation Sheet) <br />List date, tank i, and amount for all variations that exceeded the <br />allowable limits. <br />Date Tank / 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 />If the source of the variation which exceeded allowable Iiwita was dun to <br />a leak the incident #hall be reported to S.J.L.li.p. Environmental Wealth <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 />darter 2 - April-T7une7 <br />Quarter I - July -i September <br />Quarter 4 - October --> December <br />Send to; SAN JOAQUIN LOCAL HEALTH DISTRICT <br />1601 E. Hazelton, P.O. Box 2009 <br />Stockton, CA 95201 466-6781 <br />UGT 40 10/86 <br />