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4 32,� G <br />INVENTORY RECONCILIATION <br />QUARTERLY SUMMARY REPORT FORM <br />Facility Name: ! ' I',, <br />Facility Address; �c-75 e=, Mq1),/ <br />z�4�e RS2 <br />Telephone: 4fc Z -R7m7 <br />Person Filing <br />Report <br />MECEIVED <br />APR 15 1991 <br />ENVIRONMENTAL HEALTH <br />PERMIT/SERVICES <br />Tank / <br />Size <br />Product <br />rZ <br />I hereby cggify 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 />Q Inventory variations exceeded the allowable limits for this quarter. I <br />hereby certify under penalty of perjury that the source for the variation <br />W44 not due to an unauthorized (leak) release. (Yes in Column 13 of the <br />Iuveotory Reconciliation Sheet) <br />List date, tank i, and amount for all variations that exceeded the <br />allowable limits. <br />Date rank / Amount <br />I. <br />2. <br />3. <br />4. <br />5. <br />Additional dates/amouuts 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 />i <br />1 The quarterly summary report shall be submitted within 15 days of the end of each <br />quarter. <br />�acter I - �a > Narch 3 3P 9 <br />Quarter 2 - April --> June <br />Quarter 3 - July -,-> 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 />