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*" V. :" - ,,, <br /> — INVENTORY RECONCILIAi (p <br /> 'fi <br /> QUARTERLY SUMMARY REPORT FORM JUL 1 7 1991 <br /> Facility frame. � ENVPERMIENTAL LTH <br /> PERMIT/SERVICES <br /> �irt��F % .S'rP /33 <br /> /) Tank I Size <br /> Facility Address: 14;a21 -0ma Product <br /> Telephone : <br /> Person Filing <br /> Report; <br /> ❑ I hereby certify under <br /> the above penalty of perjury that all inven[o <br /> mentioned facility vete within the allowable limits for <br /> for <br /> for Chis <br /> quarter. (No in Column 13of the Inventor <br /> y Reconciliation Sheet) <br /> nventory variations exceeded the allowable limi <br /> t <br /> hereby certify under penalty of perjury that this [bervariation <br /> was not due to as unauthorized (leak) release. (Yes <br /> i° Column I1 of the <br /> love°tory Reconciliation Sheet) <br /> List date, tank /, and amount for all <br /> allowable limits. variations that exceeded the <br /> Date Tank t <br /> Amount <br /> 1. V11 <br /> 2. <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 allowable <br /> a leak the incident shall be reported to Limits was due to <br /> within 24 hours and an unaS.J .L. H . D. Environmental Health <br /> Lchorized release report submitted. <br /> The quarterly summary report shall be submitted within 15 days of the end of each <br /> quarter. <br /> Qua - --) March <br /> Qaarter 2 - April —> June <br /> Quarter u y -- -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 />