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If <br /> INVENTORY RECONCILIATION a; � 1988 <br /> QUARTERLY SUMMARY REPORT FORM <br /> ENVIROMENTAL HEALTH <br /> FERt41T/SERVICES <br /> Facility Name:s��q ,, A/ ,c ��, � Tank # Size Product <br /> G G C <br /> Facility Address: � / 614 <br /> te C> <br /> Telephone : <br /> Person Filing <br /> Report1�;,:,, <br /> E] 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 /> DInventory 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 I Amount <br /> 3. — �/ .(&) �.4 --1- 13 S <br /> 4. <br /> 5. —4- <br /> Additional dates Iamoubts 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 15 days of the end of each <br /> quarter. <br /> Quarter I - January March <br /> Quarter 2 -- April --> June <br /> Quarter 3 - July --> September <br /> Quarter 4 - October --> December <br /> Send to: SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E . Hazelton , P .O . Box 2009 <br /> Stockton , CA 95201 466-6781 <br /> UGT 40 10/86 <br />