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INVENTORY RECONCILIATION JUt.. 51988 <br /> QUARTERLY SUMMARY REPORT FORM ENVIROMENTAL HEALTH <br /> t A FERMIT/SERVICES <br /> EacLLLty Name: �1 S lank f Size P d <br /> [acility 'Address 2 l .ZO m <br /> Telephone : <br /> Person Filing <br /> Report /j� �• d�r� �� <br /> I hereby certify under penalty of perjury that all inventory variations for <br /> l y 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 uoder penalty of perjury that the source for the variation <br /> was not due to an unauthorized (leak) release. (yes in Colum 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 /> S. <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 unauthorised 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 /> iar er - Ap n --> June <br /> Quarte - July -- SepCc-her <br /> Quarter 4 - October --) December <br /> Send to: SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. Itazelton . P .O . Box 2009 <br /> Stockton . CA 95201 466-6761 <br /> UCT 40 10/ 86 <br />