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1Wj, yylT <br />INVENTORY RECONCILIATION <br />EV E <br />QUARTERLY SUMMARY REPORT FORM APR 4 1,991 <br />ENVIRON ENTLI HE/ <br />Facility Name: _12 / P� Dhair ���,,,. .�LIrl <br />Facility Address:/,3 <br />Telephone: 420 <br />Person Filing <br />Report: , <br />Tank # <br />Size <br />t <br />/ <br />/V v <br />Quarter <br />.12 <br />dU <br />--> <br />June <br />Quarter <br />3 <br />- July <br />--> <br />September <br />Quarter <br />4 <br />- October <br />--> <br />December <br />[ ] I Hereby certify under penalty of perjury that all inventory <br />variations for the above mentioned facility were within the allowable <br />limits for this quarter. (No in Column 13 of the Inventory <br />Reconciliation Sheet). <br />W-7—Inventory variations exceeded the allowable limits for this quarter. <br />I hereby certify under penalty of perjury that the source for the <br />variation was not due to an unauthorized (leak) release. (Yes in <br />Column 13 of the Inventory Reconciliation Sheet). <br />List date, tank #, and amount for all variations that exceeded the <br />allowable limits. <br />Date <br />2. <br />3. 3-.3/ <br />4. <br />5. <br />Tank # <br />Amount <br />77y <br />4:�-- 2 <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 allowable limits was due <br />to a leak the incident shall be reported to S.J.L.H.D. Environmental <br />Health within 24=hours and an unauthorized release report submitted. <br />The quarterly summary report shall be submitted within 15 days of the <br />end of each quarter. <br />Quarter <br />1 <br />- January <br />--> <br />March <br />Quarter <br />2 <br />- April <br />--> <br />June <br />Quarter <br />3 <br />- July <br />--> <br />September <br />Quarter <br />4 <br />- October <br />--> <br />December <br />Send to: SAN JOAQUIN LOCAL HEALTH DISTRICT <br />1601 E. Hazelton, P. 0. Box 2009 <br />Stockton, CA 95201 466-6781 <br />T 40 lo/86 <br />