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RECEII <br /> INVENTORY RECONCILIATION JAN 8 10"o <br /> QUARTERLY SUMMARY REPORT FORM ENVIRONMENTAL K,"ITH <br /> 1(,,;-6PERMIT/Sc„J'i''-j <br /> Facility Name: V Tank # Size Product <br /> n s 1-e ©f,C <br /> Facility Address : 940 6, l{ p TZ,D a 0 ) <br /> Telephone: <br /> Person Filing <br /> Report: . <br /> I hereby certify under penalty of perjury that all inventory variatiol <br /> for the above mentioned facility were within the allowable limits for <br /> this quarter. (No in Column 13 of the Inventory Reconciliation Sheet. <br /> Inventory variations exceeded the allowable limits for this quarter . <br /> ❑ hereby certify under penalty of perjury that the source for the varia- <br /> tion was not due to unauthorized ( leak) release. ( Yes in Column 13 of <br /> the Inventory Reconciliation Sheet ) . <br /> List date, tank It , and amount for all variations that exceeded <br /> the allowable limits . <br /> Date Tank $ Amount <br /> 1 . NdNQ <br /> 2 . —"'-�— ------ <br /> 4 . <br /> 5 . <br /> Additional dates/amounts shall be continued on a separate sheet <br /> paper and attached. <br /> If the source of the variation which exceeded allowable limits was <br /> due to a leak, the incident shall be reported to San Joaquin Local <br /> Health District; Environmental Health Division, within twenty-four <br /> ( 24 ) hours and an unauthorized release report submitted . <br /> The quarterly summary report shall be submitted within fifteen ( 15 ) days <br /> of the end of each quarter. <br /> Quarter .l - January---------->March - <br /> Quarter 2 - April------------>June <br /> Quarter 3 - July------------->September <br /> uarter 4 - October---------->December <br /> Send to: SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. Hazelton, P.O. Box 2009 <br /> Stockton, CA 95201 468-3420 <br /> 13[1 23 019 10/86 <br />