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INVENTORY RECONCILIATION '•71 <br /> QUARTERLY SUMMARY REPORT FORM JAN 2 3 1992 <br /> ENVIRONMENTAL HEALTH <br /> FaciLity Name: j��Q, �� ; Tank # Size Product <br /> l�,t•zrts �� <br /> tracilitAddress: <br /> Telephone : <br /> Person Filing <br /> Report <br /> ❑ I hereby certify under penalty of perjury that all inventory variations for <br /> the above s►entioned facility were within the allowable limits for this <br /> quarter. (No 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 unauthorized (leak) releise. (Yes in Column 13 of the <br /> Inventory Reconciliation Sheet) <br /> List date. tack f, and amount for all variations that exceeded the <br /> allowable limits. <br /> Date Tank f Amount <br /> 'f f <br /> 2. f 1 1 7 i •� r Y� ��Qom, cue-Ci-µ-e� <br /> 3. I o l2 4' <br /> 4. /p 41 Y2 r73 <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. erceeded allowable limits was due- to <br /> A leak the incident shall be reported to S .J .L.H . D. Environmental Health t� <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 I - July --> Scptemh.:r <br /> Quarter 4 - October --> December <br /> Send co: SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. Hazel cern , P .O . Box 2009 <br /> Stockton , CA 95201 466-6761 <br /> EH 23 019 10/86 <br />