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u 1 1986 <br /> INVENTORY RECONCILIATION ENVIROMENTAL HEALTH <br /> QUARTERLY SUMMARY REPORT FORM FERMIT/SERVICES <br /> hcility Names ��( a Tank <br /> Stte Product <br /> laeilkty:Addreses 122 C, W, c" a0 <br /> Z-- <br /> Telephone : y <br /> Person Flling <br /> Report Y/— <br /> I hereby certify under pemalty 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 unauthorised (leak) releise. (146 i■ Colin 11 of the <br /> Inventory Reconciliation Sheet) <br /> List date. tank /v and amount for all variations that exceeded the <br /> allowable limits. <br /> Date Tank 1 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 /> It 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 ucalth <br /> within 24 hours and an unauthorised release report submitted. <br /> The Quarterly sumsar re rt shallquarte be submitted within IS days of the and of each <br /> Quarter I - January _Mar <br /> Jar e - prt -- June <br /> Quarter ) - July --> September <br /> Quarter 4 - October --> December <br /> Send to: SAN JOAQUIN LOCAL HEALTH UISTKICT <br /> 1601 E. IlazelLi,n . 1' .0 . Nox 2009 <br /> 40 l0/HG SLockton . CA 95201 466-6761 <br /> .ICT <br />