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Q4% <br /> INVTORY RECONCILIATION /Jv <br /> QUARTERLY SUMMARY REPORT FORM <br /> hcility Nave; IOG�T/,1�/ Tank / Sire <br /> Product <br /> Facility Address: Y150 71: / quo u X t = <br /> 03 <br /> Telephone - 2 <br /> Person Filing �/ / <br /> Report <br /> 0 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 17of the Inventory Reconciliation Sheet) <br /> Ievcntary 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 unauthorised (leak) release. (Yes in column 13 of the <br /> Inventory Reconciliation Sheet) <br /> List date, tank f, and amount for all variations that exceeded the <br /> allowable limits. <br /> Date Tank I Amount <br /> 1. <br /> 2. <br /> 7. <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 varia[ i')n which exceeded alluwablc limits w s due to <br /> s leak the incident shall be reported to S „J . I. . H . D . Environmental Ilcalth <br /> within 24 hours and an unauthorised release report submitted. <br /> The Quarterly summary report shall be submitted within 15 days of the end of each <br /> Quartrr• <br /> Quarter 1 - January --) March <br /> Qtarter 2 - April --) June rr <br /> Que r to I - July --> Septcmhrr N i U77EI <br /> t--Q�Jarter 4 - October --> lkcember 1% `I///' <br /> Send co: SAN JOAQUIN I.0(:A1. HEAI.11i I)ISIRICT MAR 201989 ' <br /> 1 001 l: . l!aZt• I l u11 , P . () h...: 70119 <br /> Stockton , CA '0201 466 - 61bl ENVIRONMENTAL HEALTH <br /> 1 40 1 01 ho KWAIT/SERVICE'S <br />