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J3 <br /> � r <br /> I <br /> INVENTORY RECONCILIATION APR 9 6 1992 <br /> QUARTERLY SUMMARY REPORT FORM EIINVIRONI%%.-:N I AL HEAL HI <br /> Facility. !lame: A -9" #�Z104' Tank <br /> Size. <br /> 77 Product <br /> Ficillty:Addresss S2 N. <br /> Z . bldcled <br /> &a/C-) Zn�c' C� <br /> Telephone : Leel) q,11 - 2792/ <br /> Person Filing <br /> Report <br /> 0 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. (Ko in Column 13 of the Inventory Recorc: Sheet) <br /> _ �-� 'lint::,:. ' <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 /> i <br /> Date Tank f Amount <br /> 2. <br /> 3. <br /> 4. l ,'Pq2- 1 _ -143 <br /> 5. 11111%2- <br /> Additional <br /> 1ii %z-Additional dates/amounts shall be continued on a separate sheet of <br /> parer and attached. � <br /> If the source of the variation which. erceeded 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 Fubmitted within 15 days of the end of each <br /> Quarter. <br /> Quarter I - January --) March <br /> Quarter Z - April --) June <br /> Quarter 3 - July --) scptcmbr.r <br /> Quarter 4 - October --> (kcember <br /> Send to: SAN JOAQUIN LOCAL HEALTH DISTHIC1' <br /> 160L E . haze 1 <()n , P . 0 . 1tox 2009 <br /> Scockton ,- CA 95201 466 -6781 <br />::T 40 10/ 86 <br />