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a <br /> r INVENTORY RECONCILIATION JUL 11 1991 <br /> i <br /> QUARTERLY SUMMARY REPORT FORM ENVIRONMENTAL HEALTH <br /> PERMIT/SERVICES <br /> Fac i 1 i t T Name: 3,N)Z <br /> f Tank # <br /> Site Product <br /> Fac. ity Address: � u, <br /> � <br /> x.-.61 P-- c° � <br /> Telephone : 2� ;- f, <br /> Person ling -- <br /> Report <br /> QI hereby certify under penalty of perjury that all inventory variations <br /> C4" above mentioned facility were within the allowable limits for this for <br /> quarter. (No in Column 13of the Inventory Reconciliation Sheet) <br /> QInventory variations exceeded the allowable limits for this <br /> hereby certify under peaal[ of quarter. I <br /> was not due to an unauthorized (lerak)r <br /> Inventory Reconciliation Sheet) releaseCh(yesuineColumnh3 offor tertheion <br /> _ <br /> List date, tank #, and amount for all variations that exceeded <br /> allowable limits. the <br /> Date Tank # Amount <br /> 1 <br /> 2. <br /> 3. 25 .E <br /> r <br /> 4. <br /> 5. <br /> l Z-- i,/ <br /> Additional dates/amounts shall be continued on a separate sheet of <br /> Paper and attached. <br /> Lf the source of the variation which exceeded allowable limi <br /> a leak the incident shall be reported to as due t® <br /> S .-1 . L. Ei. D. Environmental <br /> l Eiealth <br /> ntats <br /> Within 24 hours and an unauthorized rc-lease report submitted. <br /> The quarterly summary report shall be submitted vithin IS days of the end of each <br /> qu.arcrr , <br /> Qu-1cLc. ,, I - January --) March <br /> 1:i�varter 2 - April -_> J1f1e <br /> Quarter 3 - July --> September <br /> Q1earter 4 - October --> (}ecember <br /> Send to: SAN JOAQUIN LOCAI. HEALTH DISTRIC1' <br /> 1601 F_ Hazelton , P . O . Box 2009 <br /> UCT 40 10!86 Stockton , CA 95201 466-6781 <br />