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- INVENTORY RECONCILIATION C,0- 2 19$7 <br /> QUARTERLY SUMMARY REPORT FORM ENVIROMENTAL HEALTH <br /> F..a_ci_l. _i_t_y Name: <br /> ? . A1 � FERvll/SEKVICES <br /> t <br /> Product <br /> Facility Address: / 6.S-C <br /> _ - .. .55"7 • Cin/ <br /> -77 <br /> Telephone : 2 QVoL3 770- <br /> Person Filing <br /> Report <br /> laj 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 Colu® 13 of the inventory Reconciliation Sheet) <br /> Inventory variations exceeded the allowable limits for this quarter. t <br /> hereby certify under penalty of perjury that the source for the variation <br /> was not due to an unauthorized (leak) releise. (Yes in Column 13 of the <br /> Inventory Reconciliation Sheet) <br /> List date, -tank i, and amount for all variations that exceeded the <br /> allowable limits. <br /> Date Tank E Amount <br /> 1. <br /> 2. <br /> 3. <br /> 4. <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 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 %ubmitted within 15 days of the end of each <br /> quarter. <br /> Quarter 1 - January --) March_ <br /> Quarter 2 - April --> June <br /> Quarter 3 - July --> Septemht!r <br /> Quarter 4 - October --> •cem er <br /> Send to: SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. Hazelton . P .O . [lox 2009 <br /> Stockton , CA 95201 466-6161 <br /> LICT 40 10/86 <br />