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3?� QLA P,4.71S-te. <br /> INVENTORY RECONCILIATION <br /> RECEIVED <br /> C/� OCT ' 2 19�� <br /> 1 O AARTTERLY SUMMARY REPORT FORM <br /> A ENVIRONMENTAL HEALTH <br /> Facility. Name; 41 in -4Wk-Yc7i aL PER Tank i Size Product <br /> Facility,Address: 3_ �p nJ, A.,1 -�. �j � <br /> Telephone : '4 <br /> Person n <br /> Report N, r <br /> I hereby certify under penalty of perjury that all inventoryvaria <br /> tiothe above mentioned facility were within the allowable lims for this for <br /> quarter. (No in Column 13 of the Inventory Reconciliation Sheet) <br /> i <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) 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 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 Kubmitted within 15 days of the end of each <br /> quarter. <br /> Quarter 1 - January --) March <br /> Q'13eter 2 - April --> June <br /> Quarter 3 - July --> Scptcmhi:r <br /> Quarter 4 - October --> [kcember <br /> Send to: SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 L. Hazelton . P .O . Ii()x 2O()9 <br /> Uc;T 40 10/86 Stockton , CA 95201 466-6761 <br />