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14 E <br />INVENTORY RECONCILIATION MAY 4 WO <br />4RIPEWA <br />NVIRONMENTAL HEALTH <br />QUARTERLY SUMMARY REPORT IT/SERVICES <br />Faciiity.Name: Tank # Size. Product <br />Fscf ks y Wdress: v� �U 146,T ; . <br />ov <br />Telephone: J �" <br />Person Filing <br />Report �byA,) <br />hereby certify under penalty of perjury that all inventory variations for <br />the above mentioned facility were within the allowable limits for this <br />quarter. (No in Column 13 of the Inventory Reconciliation Sheet) <br />0 Inventory 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) release. (Yes in Column 13 of the <br />Inventory Reconciliation Sheet) _ <br />List date, tank 1, 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 />5. <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 limits was due to <br />A leak the incident sh-ll be reported to S.J.L H D Environmental Mcalth <br />within 24 hours and 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 <br />- January <br />March <br />Quarter 2 <br />- April <br />--) June <br />Quarter 3 <br />- July <br />--> Septemher <br />Quarter 4 <br />- October <br />--> December <br />Send to: SAN JOAQUIN LOCAL HEALTH DISTRICT <br />1601 E. Hazelton. P.O. Box 2009 <br />kGT 40 10/86 Stockton, CA 95201 466-6781 <br />