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JAN p 8 <br /> IHVEV Y ;'•Y RECONC I L IAT ION ENVIRONMENTAL HEALTH <br /> QUARTERLY SUMMARY REPORT FOR . PERMIT/SERVICES <br /> Facility. Hame: % 'tank Size <br /> —_„ Pr <br /> GdAic t <br /> V <br /> Facility Wdress <br /> i <br /> Telephone : �1 3/,fs-J-/ <br /> Person Filing <br /> Rt p�a�i3 <br /> eporo- C <br /> l <br /> w. <br /> ElI hereby certify under penalty of perjury that all %.%ventory variations for <br /> the above mentioned facility were within the allow,04e limits for this <br /> q'saSt�.• f.t. ' n_e.. �7 <br /> ♦_v :a wain •.+ol Cuc iuvcacory Rccunci �'.atlon Jneet) <br /> k' <br /> f <br /> Inventory variations exceed.-a the allowable limits or this quarter. I <br /> hereby certify under penalio of perjury that the s,. ,rce for the variation <br /> vas not due to as unauthori; :sd (leak) releise. (Yer in Column 13 of the <br /> Inventory Reconciliation Shcnc) <br /> r <br /> I <br /> List date, tank 1, awl amount for all variati<:-ns that exceeded the <br /> allowable Limits. <br /> P= <br /> Date Tank f Amount r <br /> k <br /> 2. 90 ;z f day <br /> 3. /o ;7,?/9 a f I' 9 <br /> 4. f 7 3 <br /> S. I <br /> i <br /> Additional dateslamoitt; s shall be continued a separate sheet of <br /> paper and attached. �- <br /> 1 <br /> Ef the source of the variati :n which. exceeded al-low..,ble limits was due to Y. <br /> a leak the incident shall be reported to S .J .L.H . i). Environmental Health <br /> Within 24 hours and an unaut'iorized release report xibmitted. � <br /> The quarterlysummary ` <br /> y repoet shall be submitted within 14 days of the end of each <br /> Quarter. <br /> Quarter I - January --> March t <br /> Quarter 2 - April --y June <br /> Quarter 3 - July septembcr <br /> artec - October --> (?�cember <br /> Send to: SAN JOAQUIN LOCAL HEALTH DIST! CT <br /> 1601 E. Haze 1 Lun , P .O . Box 20(; � <br /> SLocktc-- CA 95201 466-678% z <br /> 0 <br /> EH 23 019 10/86 <br />