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RECEI VED <br />INVENTORY RECONCILIATION <br />QUARTERLY SUMMARY REPORT FORM APR 15 1991, <br />ENVIRO"QT L HEALTH <br />Facility Name: <br />Tank f ~Size <br />OduCC <br />Fac. ity Address: <br />Telephone:. <br />l <br />Person Fil g <br />Report <br />QI hereby certify under penalty of perjury that all inventory variations <br />the above mentioned facility were within the allowable limit for this <br />$ for <br />quarter. (Ho in Column 13of the Inventory Reconciliation Sheet) <br />Q Iaventory variations exceeded the allowable Limits for thisuarter. <br />hereby certify underPenaltyofperjury t I <br />he vai <br />was not due to an unauthorized (leak)release. (YesuineColumn 3 ofrtheion <br />Inventory Reconciliation Sheet) —' <br />List date, tank f, and amount foe all variations that exceeded the <br />allowable limits. <br />Date Tank I Amours[ <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 allowable limits was due to <br />a leak the incident shall be reported to S <br />Within 24 hours and an unauthorJL.Ei.D. Environmental health <br />ized release report submitted. <br />The quarterly summary report shall b4! submi <br />quarter. tted within IS 41 -'Ys of the end of e,1ch <br />Quarter 1 - Janunry "arch <br />Q1larter 2 April --> June <br />Quarter I - July --> Septcmbrr <br />Q„irter 4 - October --> 1k comber <br />to: SAN JOAQUIN LOCAL"HEALT11 DISTRICT <br />1601 "E E. Naze lton , I' .0 . Box 2009 <br />t1CT 40 10/86 Stockton, CA 95201 466-6781 <br />