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INVENTORY RECONCiLIAiIOn' t <br /> QUARTERLY SUMMARY REPORT FORM J UL 17 1991 <br /> ENVIRONMENTAL HEALTH <br /> anility Name: /�C/ /� � �F ��ldjr PERMIT/SERVICES <br /> Tank / Size Product <br /> Facility Address; I�p/ 1✓� �� �r- r <br /> 36 <br /> Telephone : <br /> Person Filing <br /> Report <br /> E] 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 Becoociliation Sheet) <br /> AInventory variations exceeded the allowzble limits Cor this quarter. I <br /> bereby certify under penalty of perjury that the source for the variation <br /> was not due to ao unauthorized (leek) release. (Yes in Column 13 of the <br /> loveotory Reconciliation Sheet) <br /> List date, tank /, and amount for all variations that exceeded the <br /> allowable limits. <br /> Date Tank f Amount <br /> 1 . <br /> 3. <br /> 4. <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 al-lowable 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 /> Quar r 1 - Januar --) March <br /> Qaarter 2 - APr—i�-) jure, <br /> -Q'"1ef----'-- —LF 0---September <br /> Quarter 4 - October --> December <br /> Send to: SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E . Hazelton , P .O . Box 2009 <br /> UGT 40 10/86 Stockton, CA 95201 466-6781 <br />