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Attn: TJnderground. t<<^..n.c d; -isior. Q T-p-L-� <br /> INVENTORY RECONCILIATION -7 ('� �_ <br /> QUARTERLY SUMMARY REPORT FORM <br /> r rc i Li ty Names <br /> is.i•�; 1 � �(�,,Q Tanit � <br /> ~ Size'. Product <br /> �acilit Addresa: o5 1,. Louise .r1ve > ` ,,er-1Tn.1_ <br /> N. - <br /> J-1: <br /> cson 2 '1 of �znlead.ed. <br /> Telephone : 2no - <br /> q r) �1 n.� <br /> Person Filing <br /> Report J011n J. SerT)_n <br /> QI hereby cer it under n er 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 Do I f the Inventory Reconciliation Sheet) <br /> T %-- <br /> tuElVED <br /> QInventory variations exceeded the allowable Limits for this quarter <br /> hereby certifyunder q rter.� 0 3 1992 <br /> penalty of perjury that the source for the vari on <br /> vas not due to as unauthorized (leak) relcise. (Yes in Column MENTAL H SALT H <br /> Inventory Reconciliation sheet) PERM IT/SERVI CES <br /> List date, tank 1, and amount for all variations that exceeded the <br /> allowable limits. /?F <br /> 2 C v� L C L� rL <br /> Date Tank Amount / lid L 44- <br /> j r <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 al-lovable limits was due: to <br /> A leak the incident shall be reported to S .J .L.H . D . Environmental Hca Ich <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 /> quarCCc. ' <br /> Quarter I - January --> March <br /> ,Qlarccr 2 - April --> June <br /> _ <br /> Qvar[ce-] - -1u1y --- ->-acptcmhcr <br /> Quarter 4 - <br /> c o cr -- Dc-comber <br /> Scnd co: SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 160L E . Ha•r.c 1 <<�n , I' .0 . Box 2001) <br /> 40 LO/86SCockton , CA -X15201 466-67& 1 <br />