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HECENED <br /> U L 1 o 19go <br /> INVENTORY RECONCILIATION LNVIRONMENTALHEALTI- <br /> QUARTERLY SUMMARY REPORT FORM PERM I /SERV110ES <br /> Facility. Names S -/{ij ,O j44 All//v/,— Tank Sise. Product <br /> FacilryCAdd+ress: S'f= I Cr GAS0 �K - <br /> Telephone : ;��7� ,_ ;f'5L <br /> Person Filing <br /> Report Ott( :S'1E:P' <br /> 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 Columa 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) releise. (Yes in Column 13 of the <br /> Inventory Reconciliation Sheet) <br /> List date, tank #, and amount for all variations that exceeded the <br /> allowable limits. <br /> Date Tank f 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 submitted within 15 days of the end of each <br /> quarter. <br /> Quarter I - January --> March <br /> Quarter 2 - April --> June <br /> Quarter 3 - July --> Septemh(tr <br /> Quarter 4 - October --> (kcember <br /> Send to: SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 160L E . HaZC I <<�n , P .0 . Box 2009 <br /> Stockton , CA 95201 466-6781 <br /> W;T 40 10/ 86 <br />