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0 <br /> INVENTORY RECONCILIATION JAN <br /> QUARTERLY SUMMARY REPORT FORM ENVIRONMENTAL HEALTH <br /> PERMIT/SERVICES <br /> Facility Name: Kio✓� Tank # Size Product <br /> • <br /> Facility Address: <br /> Telephone : <br /> Person Filing <br /> Re port <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 /> vas not due to an unauthorized (leak) releise. (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. Q ( 170 -3 <br /> 2. it 130 <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 /> wk.chin 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 /> Qjarter 2 -- April --> Jurtir <br /> Quarter ] - July --) September <br /> Q+iacCcr 4 - October =-> t)ecember <br /> Send to: SAN JOAQU IN 1,0CA1, HEAL'I'li D1-';*1'R 1 C'l' <br /> 1601 1: , <br /> .`)Lockton . CA 95101 4f,{, -61b ] <br /> 160 10/ 86 <br />