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INVENTORY RECONCILIATION <br /> QUARTERLY SUMMARY REPORT FORM <br /> Facility Name; _Z� ,5 j <br /> e lWk 9 1 Tank / Size <br /> Product <br /> raeility Address: /o f, P-Mw!ry-4 S7. <br /> Z. <br /> eAc c lG <br /> Telephone : — <br /> Person Filing <br /> Report <br /> l 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 CoLuma Ilof the loventory Reconciliation Sheet) <br /> ❑ Laventory 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 /> i <br /> List date, tank f, sad amount for all variations that exceeded the <br /> allowable limits. <br /> Date Tank f Amount n <br /> 1. I�[ � av2. 1q <br /> d_ OCT 6 1988 <br /> 4. -- ENVIRONMENTAL HEALTH <br /> S. PERMIT/SERVICES <br /> Additional dates/amounts shall be continued on a separate sheet of <br /> Paper and attached. <br /> Lf the source of the variation which exceeded allowable limits was due to <br /> • leak the incident shall be reported to <br /> Within 24 hours and an unauthorized release report sDubmittedo ntal Ilcalth <br /> The Quarterly summary report shall be submitted within 15 days of the end of each <br /> Quarter. <br /> Qua r[cr I - January --) H.trch <br /> July __ Sept emhe <br /> Qtu rtcr 4 - cto er - <br /> - •ccm to <br /> Send to: SAN JOAQUIN 1.0CAl. HE:ALTIi DIS-1-pIC-1- <br /> f 160 L E. Ilazc I l u1 , P . O . liox <br /> SLockcon , CA 95201 466-6781 <br /> 11r,T 40 10/N6 <br />