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INVENTORY RECONCILIATION <br /> QUARTERLY SUMMARY REPORT FORM <br /> Facility Name: /Y I �/ / v' I <br /> ,�l— Tank—#—P Site Pcoiiucc <br /> 7/7777- <br /> PileilityzAddreas: <br /> Ai <br /> Telephone : <br /> Person Fil <br /> Report <br /> r <br /> B//, hereby c reify under peaalgr of perjury that all inventory variations for <br /> the above mentioned facility were vithin 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 /> vas not due to an unauthorized (leak) releise. (Yes in Column 13 of the <br /> Inventory Reconciliation Sheet) <br /> List date, tank f, and amount for all variations that exceeded the <br /> allovable limits. I <br /> Date Sank f Amount <br /> 2. OCT 16 1989 U <br /> 3. ENVIROtG <br /> PERMIT <br /> 4. tS VICE,4 LiH <br /> 5. <br /> Additional dates/amounts shall be continued on a separate sheet of <br /> paper and attached• <br /> If the source of the variation which. exceeded at-lovable limits was due to <br /> a leak the incident shall be reported to S .J .L.N.D. Environmental Nealth <br /> WiChin 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 1 - Jaauary --) March <br /> Qiarter_2 - Aoril --> June <br /> C Quarter 3 - July --> Scptemher <br /> Quarter 4 - Occo er -- •comber <br /> Send to: SAN JOAQUIN LOCAL HEALTH UISI•KICT <br /> 160L E. Hazelton , P .O . 110K 2009 <br /> Stockton , CA 95201 466-67b1 <br /> EH 23 019 10/86 <br />