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INVENTORY RECONCILIATION <br />QUARTERLY SUMMARY REPORT FORM <br />Facility Name: `j /y M1oA� lM�y to <br />Facility Address; �eSpl A1. �/ l�or/�• <br />Telephone: dog �fL4�—e/i9 <br />Person Filing <br />Report �lfcT /meq l l we,!/ <br />RECEIVE <br />NOV 3 1989 <br />ENVIRONMENTAL HEALTH <br />PERMIT/SERVICES <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 Colum 1) of the loveecory Reconciliation Sheet) <br />Laventocy variations exceeded the allowable Limits for tbis Quarter. t <br />hereby certify under penalty of perjury that the source for the variation <br />was not due to an unauthorized (leak) releise. (Yes in Column 13 of the <br />laventory Reconciliation Sheec) <br />L <br />List date. tack /a and amount for all variations that exceeded the <br />allowable limits. <br />Date Tank I Amount <br />AddiCiooal 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 Ilealch <br />Within 24 hours and an unauthorised release report submitted. <br />The Quarterly summary report shall be submitted within 15 days of the end of each <br />Quarter_ <br />Quar(.-'r 1 - January <br />Qu r t.•r - -) Ju...• <br />a I - July --) Sc 1,temh.•� <br />Q"arter 4 - October --) lkcemlrer <br />Send co: SAN JOAQUIN LOCAI. HEA1.11i 01STRICT <br />1601 1{. Haze l t iul . V.0. Rns 2009 <br />SLockton• CA 95201 466-61bl <br />a' 4O 10/86 <br />