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INVENTORY RECONCILIATION APR 1 '71989 <br /> QUARTERLY SUMMARY REPORT FORM <br /> ENVii?ONMIENTAL riL.ALTH <br /> �4 ri^ <br /> PERMIT/SERVICES <br /> Facility Name: nn /�� 9 Tank i Size Product <br /> Facility Address: w�(Jr J � ,t�j\� > > K2) f <br /> Telephone : <br /> Person Filing <br /> 1 <br /> Report _�'� � / / � �c_z <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 /> Quarte, �lJI. Colt=m 13 1�f laycatcry ncca nc:11 : lOn ShceLj <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 as 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 limits_ <br /> Date Tank f Amount <br /> 1. <br /> 2. --- <br /> 3. <br /> 4. <br /> S. <br /> -r Ildditioaal dates/amounts shall be continued on a separate sheet of <br /> paper znd attached. <br /> If the source of the variation which- exceeded ahlowable limits was due to <br /> a leak the incident shall be reported to S .J .L. H . D. Environmental llcalth <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 cacti <br /> Quarter. <br /> Quarter I - January --) March <br /> Qvartcr 2 - April --> June <br /> Quarter ) - July --) September <br /> Q„arter 4 - October --) l>eccmber <br /> Send to: SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 160 1 L . Hazelton . P .O . Ro x 2009 <br /> Stockton , CA 95201 466-61151 <br /> VGT 40 10/86 <br /> I <br />