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E 0 E <br /> IS <br /> J U L 2 2 1"11 <br /> INVENTORY RECONCILIATION ENVIRONMENTAL HLALTH <br /> QUARTERLY SUMMARY REPORT FORM PERMIT/SERVICES <br /> Facil,itr Names _ 'ql�-) ),D/ Tank i Stse <br /> Product <br /> >lacilit :Address: �� �'`� <br /> r . �, iU C - orl) ,a <br /> CA 95LAc y p <br /> Telephone : ��a�i ) q11_ �,e,v <br /> O COO A <br /> Person Filing <br /> Report _ =1�CLra��< ��o✓,/% <br /> ❑ 1 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. (mo 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 unauthorised (leak) release. (Yes in Column 13 of the <br /> Inventory Reconciliation Sheet) <br /> List date, tank f, and amount for all variations that exceeded the <br /> allowable limits. <br /> Date Tank Amount <br /> t. 44JLJ J q) 1 -/-�-4 <br /> 3. 1 1 t21,? <br /> 4. <br /> S. 4�)lo�l/ I f-l1 <br /> Ildditionat dates/amounts 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 Kubmitted 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 JOAQU IN LOCAL HEALTH DISTRICT <br /> 160L E . haze 1 <<�n , P . O . Box 2009 <br /> Stockton .- CA 95201 4 6 6 -6 7 b I <br />:;T 40 10/ 86 <br />