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.7 RECEIVED <br /> INVENTORY RECONCILIATION J U L 16 Z_23 <br /> QUARTERLY S Y REPORT I'ORM <br /> ENVIRONMENTAL HEALTH <br /> cc PERMIT/SERVICES <br /> Facility Name: Tank # Size Product <br /> Facility Address : r6- <J' <br /> TelephoneC ,� <br /> Person Filing <br /> Report: . � �. G c r ) <br /> F_] I hereby certify under penalty of perjury that -all inventory variations <br /> for the above mentioned facility were within the allowable limits for <br /> this quarter. (No in Column 13 of the Inventory Reconciliation Sheet. ) <br /> In,,,, ventory variations exceeded the allowable limits for this quarter. I <br /> ereby certify under penalty of perjury that the source for the varia- <br /> tion was not due to unauthorized ( leak) release. (Yes in Column 13 of <br /> the Inventory Reconciliation Sheet) . <br /> List date, tank It , and amount for all variations that exceeded <br /> the allowable limits . <br /> Date Tank # Amount <br /> 1 . <br /> 2 . <br /> 3 . <br /> 4 . <br /> 5. <br /> Additional dates/amounts shall be continued on a separate sheet <br /> paper and attached. <br /> If the source of the variation which exceeded allowable limits was <br /> due to a leak, the incident shall be reported to San Joaquin Local <br /> Health District; Environmental Health Division, within twenty-four <br /> ( 24 ) hours and an unauthorized release report submitted. <br /> The quarterly summary report shall be submitted within fifteen (15 ) days <br /> of the end of each quarter. <br /> Quarter 1 - January---------->March 4?r. 15 <br /> Quarter 2 - April------------>June �- 11�' <br /> Quarter 3 - July------------->September (n>e 't/$ <br /> Quarter 4 - October---------->December -J- <br /> Send <br /> fSend to: SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 B. Hazelton, P.O. Box 2009 <br /> Stockton, CA 95201 468-3420 <br /> EII 23 019 10/86 <br />