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INVENTORY RECONCILIATION y <br /> QUARTERLY SUMMARY REPORT FORM JUL. 2 0 1987 <br /> ENVIROMEN AL HEALTH <br /> Facility Name: �%liaLP00'1/�,yruR� Eh•„y C- *6,c. Tank IT/ ERVfeE6duct <br /> q C��uw <',l <br /> Facility Address: Jyf e effAeTc,G Ldp� ? , G, ua LI <br /> Telephone : 46,7- 03`1. <br /> Person Filing <br /> Report K1*1_P00n) <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 13 of 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 /> was 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 alE 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. erceeded at-Lovable 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 /> garter 2 April <br /> Quarter ) July --> September <br /> Quarter 4 - October --> lkcember <br /> Send to: SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E . Hazelton . P . 0 . 1iox 2009 <br /> Stockton , CA 95201 466-67b1 <br /> Ur,T 40 10/86 <br />