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INVENTORY RECONCILIATION �p '� X987 <br /> QUARTERLY SUMMARY REPORT FORM ENVik' !vttiTAL HEALTH <br /> ERM,11/SERVICES <br /> Facility Name; iag V1')n Sib/®u , ,}kern r.5 4 6Vre _ Tank I Site_ Product <br /> /2v✓o QBeulur <br /> Facility Address: i <br /> . X%,'-;kTn/V rA. %C2 C' <br /> Telephone : <br /> Person Filing <br /> Report A�1,gLDn� z,Tyylt/ <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. I <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 /, 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 /> S. <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 allowable 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 IS days of the end of each <br /> Quarter. <br /> Quarter I - January March <br /> Quarter 2 - April --> June <br /> Quarter ) - July --) Scptem er <br /> .r Quarter 4 - October --> December <br /> Send to: SAN JOAQUIN LOCAL HEALI.1i DISTRICT <br /> 1601 E. Haze 1 t o�n , P . O . Box 2009 <br /> Stockton , CA 95201 466-67bl <br /> Uc,T 40 10/86 <br />