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INVENTORY RECONCILIATION APR 17 1991 <br /> QUARTERLY SUMMARY REPORT FORM ENVIRONMENTAL HEALTH <br /> PERMIT/SERVICES <br /> Facility Name: M\/ Am, Iyi7-1 Tank f _ Size Product <br /> n <br /> Facility,Address: % C /V F - 6$ <br /> — TN <br /> Telephone : a D � ) �1 , , <br /> Person Filidg <br /> Report 6/¢1.4D /✓- <br /> l�J 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 Coln® 13 of the Inventory Reconciliation Sheet) <br /> El Inventory variations exceeded the allowable limits for this quarter. Y <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, tack 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 dates/amounts shall be contioued on a separate sheet of <br /> paper and attached. <br /> Lf 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.O. 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 I - January --) March <br /> Quarter 2 - April June <br /> Quarter 3 - July --) September <br /> Quarter 4 - October --) Ikcember S <br /> Send CO: SAN JOAQUIN LOCAL HEAL1'li UIS"rKICT <br /> 1601 1.. Haze I toll . P .O . Box 2009 <br /> Stockton . CA 95201 466-67b1 <br /> EH 23 019 10/86 <br />