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INVENTORY RECONCILIATION <br /> QUARTERLY SUMMARY REPORT FORM JAN 2 3 113130 <br /> ENVIRONMENTAL HEALTH <br /> Facility Name. , ,! PERMIT/SERVICES <br /> � Tank I Size <br /> Product <br /> Facility Address; <br /> Telephone : �a �y :A27_��,,,;.,. <br /> Person Filing <br /> Report z,��t'�r�t��/'/ i�* ' <br /> I hereby certify under penalty of perjury that all inventory variations for <br /> 'be above mentioned facility were within the allowable limits for this <br /> quarter. (Ho is Column 13 of the Inventory Reconciliation Sheet) <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 not due to an unauthorized (leak) release. (Yes in Column 13 of the <br /> Inventory Reconciliation Sheet) '— <br /> List date, tank I, and amount for all variations that exceeded the <br /> allowable licnita. <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 ..1 . L . H . D . Environmental Health♦rithi. 24 hours and an unauthorized release report submitted. <br /> The Quarterly summary report shall be Rubmitced within IS days of the end of each <br /> quar(er_ <br /> Quarter 1 - January --) March <br /> Qvarccr 2 - April --) June <br /> Quarter ) - July --> September <br /> Q�actcc 4 - Oc[obcr --) lkccml,--- <br /> Send Co: SAN JOAQu I N LOCAL HEALTH DISTRICT <br /> 1601 E . 11.nrc 1 t o�n , p . 0 . ItOx <br />)(;1' 40 10/86 Stockton , CA 05201 466 -67b1 <br /> e <br />