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INVENTORY RECONCILIATION OCT 1 G 1993 <br /> QUARTERLY SUMMARY REPORT FORM <br /> ENVIRONMENTAL HEALTH <br /> T ERV�CES <br /> Facility Name: /f 1;'4C/ Tank I Size Product <br /> Facility Address: ��~S^ A). Oa 41 &+ <br /> 3 ! <br /> opliPc 9 Ef SQr��G <br /> Telephone : 00 g - 072�t / <br /> Person Filing <br /> Report �/',��/ .Tc k0o /do S�,' <br /> E] I 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 Column 13 of the Inventory Reconciliation Sheet) <br /> QInventory variations exceeded the allowable Limits for this quarter. I <br /> h1reby certify under penalty of perjury that the source for the variation <br /> vas not due to an unauthorized (leak) release. (Yes in Colum 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 # Amount <br /> 2. <br /> 3. Jze <br /> 4. � ' C C 000/Fr(933 <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 _I, H _ U Environmental Health <br /> within 24 hours and an unauthorized release report submitted. <br /> The quarterly summary report shall be Submitted within CS days of the end of each <br /> quarter- <br /> Quarter € - January --> March <br /> Q►aarter 2 - April --> June <br /> Quarter 3 - July --> September <br /> Quarter 4 - October --) December <br /> Send to: SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E . Haze 1 t on , P .O . Box 2009 <br /> Stockton , CA 95201 466-6781 <br /> UGT 40 10/ 86 <br />