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r q�� JAN 5 <br /> ENVIRONMENTAL AL OCALT�j <br /> INVENTORY RECONCILIATION <br /> QUARTERLY SUMMARY REPORT FORM PERMIT/SERVICES <br /> Facility Name: K99 !'13�P0, r• Tank <br /> Size Product <br /> Facility Address; <br /> BOQ-N7r�!OAl A-r!f , <br /> Telephone : soy dad- 9szf / <br /> Person Filing <br /> Report 13,/1",,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. (N0 in 07l,� 113 =f <br /> J „q •_ I . <br /> �_ 1 - th.: u'-?catory ReCOncillation beet) <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 oot due to an unauthorized (leak) release. (Yes in Column IJ 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. <br /> 4. <br /> 5. <br /> Additional dates/amounts shall be continued on a separate sheet of <br /> paper a"d atcaliled. <br /> If the source of the variation whichexceeded 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 /> Quarter 1 - January --) March . <br /> Qlarter 2 - April --> June <br /> ,9uarter 7 - July --) September <br /> ✓Quarter 4 October --) December <br /> Send to: SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. Hazelton , P .O . Box 2009 <br /> Stockton , CA 95201 466-67b1 <br /> GT 40 10/86 <br />