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-. ..- - V INVENTORY RECONCILIATION <br /> QUARTERLY SUMMARY REPORT FORM JUL 5 1989 <br /> FacilityName: <br /> ...__. _. A�mr� m f 12C1�51� (�(, Tank i - coduct <br /> Facility.-Address: r OF <br /> `T <br /> Te lephone : Lc2q —1-145 -b'jo <br /> Person Filing <br /> - - - Report <br /> I hereby certify under penalty of perjury that all inventory variations for <br /> the above mentioned facility were vithin the allovable limits for this <br /> quarter. (No in Column 13 of the Inventory Reconciliation Sheet) <br /> QInventory 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, tank f, and amount for all variations that exceeded the <br /> _allowable limits. <br /> Date Tank f Amount <br /> 1. <br /> 2. <br /> 3. <br /> 4. <br /> S. <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.H . D. Environmental Health <br /> within 24 hours aad 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 - January --) Harch <br /> 'artec - April --> June <br /> Quarter 3 - July --) Scptemh.!r <br /> Quarter 4 - October --> Ikcember <br /> Send to: SAN JOAQUIN WCAL HEALTH U1STRICC <br /> 1601 E. Haze 1 t (ln , P .O . .11ox 2009 <br /> Stockton , CA 95201 466-6761 <br /> LILT 40 10/86 <br />