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®� /9oF3 <br /> INVENTORY RECONCILIAT 't - � <br /> QUARTERLY SUMMARY REPORT FOS` ,t'1T a1- 'EALSH <br /> OA <br /> p 93 JU - <br /> Facility. Name: Tank i <br /> 1 Product <br /> Facility Addreaa; 3 3Q T" Q„ <br /> Telephone : <br /> Person Mpg <br /> Report <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 Column 13 of the Inventory Reconciliation Sheet) <br />. I <br /> ElInventory variations exceeded the allowable limits for this quarter. I <br /> hereby certify under penalty of perjury that the source for the variation <br /> vis not due to an unauthorized (leak) releise. (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 f Amount <br /> 1. <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 at-lowable limits was due: to <br /> a leak the incident shall be reported to $ ,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 1 - January --> March <br /> Quarter 2 - April --> June <br /> 3 Quarter 3 - July --> September <br /> Quarter 4 - October --) December <br /> Send co: SAN JOAQUIN LOCAL HEALTH UISTRICt' <br /> 1601 E. Hazelton . 1) .0 . Box 2009 <br /> Stockton , CA 95201 466-6761 <br /> LILT 40 10/86 <br />