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�i <br />QUARTERLY SUMMARY REPORT FORM <br />Facility Name: <br />F4cili.ty,Addrems: <br />14971 N. HwV. 88 <br />m • • a .3s <br />Tele• • <br />Person Filing <br />Report <br />PERMf t �FF2-iifrac <br />P herebyunder <br />abovethe y o. Ir facility were <br />variations for <br />quarter,within the allows inventory <br />(NO in Column 13of the Inventory Reconciliation Sheet) <br />0 Inventory 'Variations exceeded the allowable <br />herebr.liiL for ;this quarter. I <br />y certify under Penalty <br />• 1 ;". <br />perjurythat the <br />source for the variation <br />V48 oat due tO an unauthorized is <br />e�se. (Yes in Column 13 of the <br />Inventory <br />Reconciliation <br />Last datev tank f, and amount for all variations that exceeded the <br />allowable Iiinitg. <br />Date Amount <br />1. <br />. <br />. <br />4. <br />5. <br />Additional dates/ unts 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 :hall be reported to S.J.L.H.D. Environmental lleaICh <br />Within 24 hours and an unauthorized release report submitted. <br />The quarterly summary report shall be xubmitted within 15 days of the end of each <br />quarter. <br />Quarter I - January --> March <br />Quarter 2 !April --> June <br />Quarter ) - July --> Scptemhe^r <br />Quarter 4 - October --> Occember <br />Send to: SAN JOAQU IN LOCAL HEAL1'1i DISTRICT <br />1601 E. l:azc• ! l <►„ , I? .0 . liox ZOOo <br />40 10/Fib Stockton, CA 95201 460-61bl <br />' <br />