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J U L 15 1992 <br />INVENTORY RECONCILIATION ENVIRONMENTAL HEALTH <br />QUARTERLY SUMMARY REPORT FORM PERMIT/SERVICES <br />Facility Name: <br />'"t WAL'S CAS r" -- <br />Facility Address: 4100 E- FREk1,,.)ry ' <br />Telephone :� <br />Person Filing <br />Report <br />Tank I Size Product <br />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 I3 of the Inventory Reconciliation Sheet) <br />QInventory 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 1, and amount for all variations that exceeded the <br />allowable limits. <br />Date $ Tank f Amount <br />2. <br />3. <br />4. <br />S. <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 licalth <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 />actor I <br />Q'laCter 2 <br />Quarter 3 <br />Q„arter 4 <br />Send to: <br />tic -1. /.0 1O/ti() <br />- January --1 March <br />- April --> June <br />- July --> September <br />- October --> [)ecember <br />SAN .JOAQU IN LOCAL HEAL -1-11 <br />1601 L. Haze I i (m . 1' . 0. It,):•; )OW) <br />Stockton. CA 95201 4(,(,-()7b1 <br />& H.F <br />N <br />