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L✓•IJ fP�l�on /jf �✓ <br /> 72 rr-z L <br /> INVENTORY RECONCILIATION <br /> QUARTERLY SUMMARY REPORT FORM N",GV 2 C. E9R7 <br /> ENVIROMENTAL HEALTH <br /> /cFRVICES <br /> facility Name: K�,ne z7nyi✓ Na-4e-2 &D (r,4 f c. Tank eProduct <br /> facility Address: �oJ <br /> U LE r <br /> C4 19C 2,C74 <br /> Telephone : y67- 0305 <br /> Person Filing <br /> Report --fi r;'�n„� y: ai VM'P1W <br /> 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 13of the Inventory Reconciliation Sheet) <br /> Inventory variations exceeded the allowable limits for this quarter. t <br /> hereby certify under penalty of perjury that the source for the variation <br /> vas not due to an unauthorized (leak) release. (Yes in Column 13 of the <br /> Inventory Reconciliation Sheet) <br /> List date, tank f, sad amount for all variations that exceeded the <br /> allowable limits. <br /> Date Tank i Amount <br /> 1. <br /> 2. <br /> 3. <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 variation which- exceeded allovable limits was due to <br /> a leak the incident shall be reported to S .J .L. H . D . 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 =->_septem_hcr) <br /> Quarter-4 - cto6cr --) December <br /> Send to: SAN JOAQU IN LOCAL HEALTH DISTRICT <br /> 1601 I�,. Haze 1 ton , I' .0 . Roux 2009 <br /> Stockton , CA x/5201 466-6761 <br /> UGT 40 10/86 <br />