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MAR pp- (U� <br /> INVENTORY RECONCILIATION <br /> QUARTERLY SUMMARY REPORT FORM ENVIROMENTAL HEALTH <br /> f FERMIT/SERVICES <br /> Facility Name;�gyyq 1 (uw/L �% ffr, 7` !Tank 1 Size Product <br /> SlaeCryo t� 1 IGIOO <br /> Facility Address: <br /> 3 /Lbd Ui�ddP� <br /> syoCCrnA/ 04 4�2o1 <br /> Telephone : yG3 --'2c/63 <br /> Person Filfo9 <br /> Report �SOc Ude , ezo <br /> L 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 Columa 13of the Lnventory 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 unauthorized (leak) releace. (Yes in Column 13 of the <br /> Inventory Reconciliation Sheet) <br /> List date, tank 1, and amount for all variations that exceeded the <br /> allowable limits. <br /> Date Tank I Amount <br /> 1_ <br /> 2. <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 /> within 24 hours and an unauthorized release report submitted. <br /> The quarterly summary report shall be Fubmitted within 15 days of the end of each <br /> quarter_ <br /> Quarter I - January --) March <br /> Quarter 2 - April --> June <br /> a reef - July --> Scptcmhcr <br /> Quarter - October --> December <br /> Send to: SAN JOAQUIN LOCAL HEAL1'li DISTRICT <br /> 1601 E . Hazelt(in . P . O . lion 2007 <br /> Stockton , (:A 75201 466-6781 <br /> UGI' 40 10/86 <br />