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INVENTORY RECONCILIATION <br /> ' JAN 41989 <br /> QUARTE LY SUMMARY REPORT FORM <br /> p ENVPLTEI <br /> ERMIT I SERVICES <br /> Facility Name : L Tank # Size Product <br /> Facility Address : S 3 - t <br /> 11eA " C'-' ,�s <br /> Telephone : 'ZO - !0 00 C <br /> Person Fili - <br /> Report : ROke 1- krf A PP <br /> [ ] I Hereby certify under penalty of perjury that all inventory <br /> variations for the above mentioned facility were within the allowable <br /> limits for this quarter. (No in Column 13 of the Inventory <br /> Reconciliation Sheet ) . <br /> [ <br /> ] Inventory variations exceeded the allowable <br /> sourcethis <br /> forquarter. <br /> I hereby certify under penalty of perjury <br /> variation was not due to an unauthorized (leak) release . (Yes in <br /> Column 13 of the Inventory Reconciliation Sheet ) . <br /> List date , tank # , and amount for all variations that exceeded the <br /> allowable limits . <br /> Date Tank # Amount <br /> 1 . <br /> 2 . <br /> 3 . <br /> 4 . E=--- <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 limits was due <br /> to a leak the incident shall be reported to S.J.L.H.D. Environmental <br /> Health within 24:--hours and an unauthorized release report submitted . <br /> The quarterly summary report shall be submitted within 15 days of the <br /> end of each quarter. <br /> Quarter 1 - January --> March <br /> Quarter 2 - April --> June <br /> Jul --> <br /> Quarter 3 - Y September <br /> Quarter 4 - October --> December <br /> Send to : SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. Hazelton, P. 0. Box 2009 <br /> Stockton, CA 95201 466-6781 <br /> T 40 10/86 <br />