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01�Lqzaw4o <br /> INVENTORY RECONCILIATION <br /> QUARTERLY SUMMARY REPORT FORM APR 2 61989 <br /> ENVIRONMENTAL HEALTH <br /> -MVFacility Name: eAe4 j{ /TMT. Tank i Stze Product <br /> < J-C - <br /> Facility Address: J7o-�/�[yp 0 �}�G j Sc P <br /> N7l�iyr+riLf1_ c'A 9i: �E. <br /> Telephone : „209 3;33 - 9,�2S/ <br /> Person Filing <br /> Report ,6,11 X1407 4 <br /> ® 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 /> ElInventory 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) release. (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 /> /1/Okw 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 submitted within 15 days of the end of each <br /> quarter. / <br /> Y Quarter I - January --> March . <br /> Quarter 2 - April --> June <br /> Quarter 3 - July --) Septemher <br /> Quarter 4 - October --) December <br /> Send to: SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. laze1ton , P .O . Box 2009 <br /> Stockton , CA 95201 466-67b1 <br /> IGT 40 10/86 <br />