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INVENTORY RECONCILIATION <br /> QUARTERLY SUMMARY REPORT FORM ENVIROMENTAL HEALTH <br /> So,ri4 Foo-D 4 Cud L CO. FERMIT/SERVICES <br /> Facility Name: �ESca.lew. `I�taeen, Tank # Size Product <br /> 0 Doo p sa sr i0 <br /> Facility Address: i$aS S. ESeslew Aw /O 000 L. <br /> ESc&t-. p CA 4S310 .3 R g LEAD <br /> Telephone : .764-93a,- 7753 /2s�= <br /> Person Filing <br /> Report Ma-k- D, 5e.Qso ae... fa�4ntr <br /> I 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 Column 13of the inventory Reconciliation Sheet) <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 #, and amount for all variat' -- <br /> allowable limits. S��E <br /> Date Tank # Amount <br /> 1. <br /> 2. (?tie-F 3vapenst dOc�Mt +s <br /> 3. WGrt �G ..por�r ly n�:spltcc <br /> 4. <br /> Additional dates/amounts shall be continued <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 submitted within 15 days of the end of each <br /> quarter. <br /> Quarter I - January --> March <br /> Quarter 2 - April --> June <br /> Quarter 3 - July --> September <br /> Quarter 4 - October --> December <br /> Send to: SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E . Hazelton , P .O . Box 2009 <br /> Stockton , CA 95201 466-6781 <br /> UGT 40 10/86 <br />