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--- -- INVENTORY RECONCILIATION <br /> QUARTERLY SUMMARY REPORT FORM <br /> _. -F—a.c._i. l. i._t7 Name: <br /> . ........ ? � / <br /> ... Tank <br /> - - Product <br /> lacilit Address: t 1.; /777 v /r� L <br /> _. .__ Telephone : rZO-�� E.,5!L- 07?0 <br /> Person Filing <br /> Report <br /> PX 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 13 of the Inventory Reconciliation Sheet) <br /> �._ Inventory variations exceeded the allowable limits for this quarter. I <br /> hereby certify under penalty of perjury that the source for the variation <br /> was not due to an unauthorized (leak) release. (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 /> 2.3. <br /> I tt <br /> 4. <br /> EmIRUMt:NTAL HEALTH <br /> S• PERMIT/SERVICES <br /> Additional dates/aasounts 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 /> Quarter i - Jaouary --> March <br /> Quarter 2 - April --> June <br /> Quarter 3 - July --> Scptcmbcr <br /> Quarter 4 - October --> December <br /> Send to: SAN JOAQUIN LOCAL HEALTH UIS-1'K1C1' <br /> 1601 E. Hazelton . 11 .0 . Box 2009 <br /> Stockton . CA 95201 466-6761 <br /> UCT 40 10/86 <br />