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• � �a � rr I�l� <br /> INVENTORY RECONCILIATION ,)L", 1 lSHD <br /> QUARTERLY SUMMARY REPORT FORM ENVIROMENTAL HEALTH <br /> F ERtti�IT1`Er�.�lr_.�S <br /> FaeiLity Name: t �/ � �/ri�f jam, Tank / Size Product <br /> -1000 U14 ?il/i VELI /LOQ <br /> Facility 'Address: U iii ro Y ' ly— a xLWc <br /> Lam 69- <br /> Telephone : <br /> 9 Telephone : / 209) - <br /> Person Filitffg ` <br /> Report 14O <br /> hereby certify under penalty of perjury that all inventory variations for <br /> the above mentioned faciiity were within the allowable limits for this <br /> quarter. (No in Column 13 of the Inventory 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) releise. (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 f Amount <br /> 1. <br /> 2. <br /> 3. <br /> 4. <br /> 5. <br /> Additional daces/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 dueto - <br /> a leak the incident shall bereportedto. S .J .L.H . D. - Environmental licalch. <br /> Within 24 hours andan unauthorized release report submitted.. - <br /> The Quarterly summary report shall be submitte4 within 15 days of the end of each <br /> quarcer- <br /> .Quarter -1 January -->- March - - - <br /> Quarter 2 - - April -->: June - - <br /> Quarter 3 - July - --> septemher <br /> Quarter 4 - October --> December <br /> Send co: SAN JOAQUIN 1,0CA1, HEALTH DISTRICT <br /> 1601 V . Hazello" . P .O . Itox 1009 <br /> SLockcon . CA 95201 466 -6761 <br /> 1(:T 40 10/86 <br />