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ENTCONCILIATION <br /> QUr RLy SUMMARY REPORT FORM* <br /> �--►ls�t� � Tank Size Pradtict <br /> Facility Name: � �C►�wrs ' - l 1�,CaOca ►a�. ��. <br /> Facility Address: 'ZI <br /> Telephone: Z.o9 8Z3 2 51 <br /> Person Filing Iscl <br /> Report: YAL4Z� ;.%=- Qs <br /> I hereby certify under penalty of perjury that all inventory <br /> variations for the above mentioned facility were within the <br /> allowable limits for this quarter. (No in column 13 of the <br /> Inventory Reconciliation Sheet. ) <br /> Inventory variations exceeded the allowable limits for this <br /> quarter. I hereby certify under penalty of perjury that the <br /> source for the variation was not due to authorized (leak) <br /> release. (Yes in Column 13 of the Inventory Reconciliation <br /> Sheet) . <br /> RKEIVU14 ate, tank #, amount for all variations and the reason <br /> Elerxceeding the allowable limits. <br /> JAN 13 1992e` ason <br /> Date Tank Amount R <br /> ENVIRONMENTAL HEALTH —I zo <br /> PERM IT/sERWL a- of -91 <br /> 2. l - is-q 1 l f ►.s.� rn a <br /> 3 . kt>- 29 -91 <br /> 4. 1 D-5�1 -`( <br /> 5. <br /> Additional dates/amounts shall be continued on a separate <br /> sheet of paper and attached. <br /> If the source of the variation which exceeded allowable limits <br /> was due to a leak, the incident shall be reported to Public <br /> Health Services of San Joaquin County Environmental Health <br /> Division, within twenty-four (24) hours and an unauthorized <br /> release report submitted. <br /> The quarterly summary report shall be submitted within fifteen (15) days of <br /> the end of each quarter. Circle appropriate quarter. <br /> Quarter 1 - January---------->March <br /> Quarter 2 - April ----------->June <br /> er 3 - July ------------->September <br /> C Quarter - October ---------->December <br /> Send to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> {ts NSr�� L9rri�i4F --A �• , P.O. Box 2009 <br /> !� Stockton, CA 95201 <br /> (209) 468-3420 <br /> EH 23 019 (10/89) <br />