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,uq <br /> h�g 0 b5987 <br /> INVENTORY RECONCILIATION ENVIROMENTAL HEALTH <br /> QUARTERLY SUMMARY REPORT FORM FERMIT/SERVICES <br /> /� <br /> Facility Name: yv\ 17 � '�il:� --Tank-# Size Product <br /> �-\ qv <br /> Facility Address: 2 <br /> 1 O /k r <br /> Telephone : 20 - <br /> Person Fili>I \ <br /> Thereby 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 variations that exceeded the <br /> allowable limits. <br /> Date Tank / Amount <br /> 1. <br /> 2. <br /> 3. <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 each <br /> quarter. <br /> Quarter 1 - 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 L . Hazelton , Y .O . Box 2009 <br /> Stockton , CA 95201 466-6781 <br /> UGT 40 10/86 <br />