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INVENTORY RECONCILIATION <br /> p�. <br /> r <br /> QUARTERLY SUMMARY REPORT FORM <br /> FacilityName: <br /> k Tank # Size Product <br /> R <br /> ''"aei'lity Address s, <br /> �.� <br /> - 'm elephone,c <br /> 00 <br /> �s �rs on Filing <br /> I hereby certify under penalty of perjury that all inventory va ri.atic, <br /> x,t <br /> for the above mentioned ,facility were within the allowable limits for <br /> k this quarter. (No in Column 13 of the Inventory Reconciliation Shec,�. .. <br /> z <br /> Inventory variations exceeded the allowable limits for this quarter . <br /> hereby certify underenalt of <br /> y per <br /> jury that the source for the var' <br /> tion was not due to unauthorized ( leak) release. (Yes in C01,Umn 13 <br /> the Inventory Reconciliation Sheet) . <br /> List.,,+ ate, <br /> ` tank and amount for. all variations that exceeded <br /> the 'allowable limits. <br /> p <br /> ='k ` Dittt' <br /> Tank # Amount <br /> RECEIVEDr <br />$4w 2'*' <br /> JUL 0 3 1990 <br /> ENVIRONMENTAL HEALTH <br /> PERMIT/SERVICES <br /> Additional elates/amounts shall be continued on a separate sheet <br /> paper';-and attached . <br /> 1 C the ou ee ,`ofd the variation which exceeded allowa,k ie Aimljjts was <br /> �tue': to' a leak, � the incident shall be reported to San Joaquxit Local <br /> �F e IIor th Distrsct,' Environmental health Division, within twenty-four <br /> (24 ) h- iurs 'and an unauthorized release report submitted. <br /> ' y`k'lte <br /> quarterly summary r6port shall be submitted within fifteen (15f days <br /> est the end of each quarter. <br /> Quart t 1 January-r--_------>March <br /> tor 2 - April <br /> te <br /> carr 3--=' July---- ....----_>Scpternlaer <br /> Quarter. 4 - October--w--__--'- -->Dec ember <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 16 ?1 R. Hazelton, P.O. Box 2009 <br /> ;r Stockton, CA- 95201 466--3420 <br /> ( tl ` 23 `'019 10/8'6,: ,, <br />