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RECEIVEDa.. ; .rh`.. <br /> JUL 17 1991 INVENTORY RECONCILIATION <br /> ENVIRONMENTALHEALT�bARTERLY SUMMARY REPORT FORM <br /> PERMIT/SERVICES <br /> FaciLit Names S ,� dL ' <br /> 7. -0,9-5 fl MIP/!'( `G Tank Sise. Product <br /> FacilityAddress <br /> ; <br /> Telephone :' old/r' —6" <br /> Person Filing , <br /> Report btlnl Sud <br /> I herebycertify under n` <br /> y 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 13of the inventory Reconciliation Sheet) <br /> W. <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 1, and amount for all variations that exceeded. the- <br /> allowable limits. {� <br /> Date Tank f Amount �✓ �' <br />_-_ 2. <br /> 3. <br /> 4. <br /> 5. <br /> Additional dates/amounts shall be continued on : separate sheet cf " <br /> paper and attached. <br /> It the source of the variation which. exceeded allowable limits was due to <br /> *� leak the incident shall be reported to Environmental kicaIth <br /> p S .J .L.H . D. <br /> Within 24 hours and an unauthorized release report submitted. <br /> The quarterly summary report shall be submitted within 15 days of theend of each <br /> quarter- <br /> Quarter 1 - January --) March <br /> Quarter 2 - April --> June <br /> Quarter 3 - July --> September <br /> Quarter 4 - October --> Drcember <br /> Send to: SAN JOAQUIN LOCAL HEALTH UISTRICI' <br /> 160L E . Haze 1 <on , P .O . Box 2009 <br /> k <br /> Stockton , CA 95201 466-6781 <br /> W;T 40 10/ 86 <br />