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♦ �t .�,. 9R�N n M..,y. <br /> INVENTORY RECONCILIATION <br /> QUARTERLY SUMMARY REPORT FORM AUG 2 <br /> ENVIF(OWLENTAL HEALTH <br /> OL <br /> Facility Name: __d,gt,al�t?hl tN'�ccQ� Tank i <br /> �� oduct <br /> Facility•Address: <br /> moo!t, c�A�TE,e w4717 <br /> � <br /> Telephone : <br /> Person Filing �- <br /> Report (?o /� �� 0301' <br /> OI hereby certify under penalty of perjury that all inventory variations fo <br /> 'be above mentioned facility were within the allowable limits for this r <br /> Quarter. (No in Colum= 13of the Inventory ReconA:li;tions S;eet) <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) release. (Yes in Column13 of the <br /> Inventory Reconciliation Sheec) ._ <br /> List date. tank /, and amount for all variations that exceeded the <br /> allowable listita. <br /> Date Tank f Amount <br /> 1. <br /> 2. <br /> 3. <br /> 4. <br /> S. <br /> Additional dates/amounts shall be continued on a separate sheet of <br /> paper and attached. <br /> i <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 Ilealth <br /> within 24 hours and an unauthorized release report submitted. <br /> The quarterly summary report shall be aubmitced within 15 days of the end of each <br /> quarter. <br /> QuaCCCC ( - Januar --) March <br /> / Qaar[cr 2 - April --> Julie ; <br /> Quarter 31p cmhr.r <br /> Q%.arter 4 - October --) D9.cemt,er <br /> Send CO: SAN JOAQUIN LOCAL HEA1.1Ii DISTRICT <br /> 1601 E . Hazelton . I' . 0 . It<�x ZOO') <br /> ;T 40 10/ H6 Stockton , CA 95201 466-67bI <br />