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• • pgraawq <br /> INVENTORY RECONCILIATION OPT t, 1gR7 <br /> QUARTERLY SUMMARY REPORT FORM <br /> p() ENVIROMENTAL HEALTH <br /> Facility Name: EAI k duct <br /> Facility Address: (.e9 �'�� ,Vim- Z oz LA%A . - <br /> ln. rk� <br /> Telephone : ZD4 — 133- 477 <br /> Person Fili�ng tA/� <br /> Report .IA01r, uV1 "^V-,.ANAL, <br /> E] 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 17 of 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 D of the <br /> Inventory Reconciliation sheet) <br /> List date, tank 1, and amount for all variations that exceeded the <br /> allowable limits. <br /> Date Tank f Amount RECEIVED <br /> 1.2. <br /> V I C.' tV411 <br /> s. ADS?..... . . <br /> 4. <br /> 5. <br /> Additional 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 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 cacti <br /> quarter. <br /> Quarter I - .Yanuary --) March <br /> Quarter 2 - Aprit --> Junc <br /> Quarter J - July --) September <br /> Quarter 4 - October --> Occember <br /> Send to: SAN JOAQUIN LOCAL 11GA1J11 DISTRICT <br /> 1601. F . Hazclton , P .O . ltox 7009 <br /> SLocicLon , CA 95701 466-6781. <br /> UGT 40 10/86 <br />