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a ep^ak� s' p '3J <br /> INVENTORY RECONCILIAi [Ov..i APR � 7 14Q1 <br /> QUARTERLY SUMMARY REPORT FORM cN I 0 ENTAL HEALTH <br /> Facility Na.,: ��/ ("/F' /( � /� 337 )fe � IT/SERVICES <br /> Tank / Size P oduct <br /> Facility Address: S �G;C� c <br /> G�r�1 <br /> —L�_ r✓�_� G i G <br /> Telephone : ' � n <br /> Person Filin <br /> Report <br /> I hereby certify under penaltyof � C/C// C �c1} c✓— <br /> the above mentioned facility were within theaallowahleall elimi[evforaChoss for <br /> quarter. (Ho in Columo I3of the Inventory Reconciliation Sheet) <br /> Inventory variations exceeded the allowable limits for this quarter. I <br /> hereby certify soder pe <br /> to <br /> of perjury that the source for the variation <br /> was not due to as soauthorized (leak) release. (Yes in Column I] of the <br /> lnvcatory Reconciliation Sheet) -- <br /> List date, tank /, sad amount for all var <br /> allowable limits. iations that exceeded the <br /> Date Tank / <br /> Amount <br /> 2. <br /> J. <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 limits was due to <br /> a leak the incident shall be reported to <br /> Within 24 hours and an unauthorized release reporlt submittedonnental Health <br /> The quarterly su—'ry 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 <br /> __- --> September <br /> Quarter 4 - October --> December <br /> / Scnd to- SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E . Hazelton , P .O . Box 2009 <br /> UGT 40 10/86 Stockton , CA 95201 466-6781 Au <br /> -IJ J" 14�7 amu " �' <br />