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Facility Name: <br />Facility Address: <br />Telephone: <br />Person Filing <br />Report:. <br />0 0 <br />INVENTORY RECONCILIATION <br />QUARTERLY SUMMARY REPORT FORM <br />CVJ � G l` 0 (-.,j .7 � Tank # <br />"7/ S iNpcQ <br />s, 'rtv <br />Size Product <br />I hereby certify under penalty of perjury that all inventory variations <br />F� for the above mentioned facility were within the allowable limits for <br />this quarter. (No in Column 13 of the Inventory Reconciliation Sheet.) <br />Inventory variations exceeded the allowable limits for this quarter. I <br />[X] <br />hereby certify under penalty of perjury that the source for the varia- <br />tion was not due to unauthorized (leak) release. (Yes in Column 13 of <br />the Inventory Reconciliation Sheet). <br />List date, tank #, and amount for all variations that exceeded <br />the allowable limits. <br />Date Tank # Amount <br />2* 121 <br />3. <br />ZS4 4f <br />4. Qao,04eww <br />5. eHl�iNf w•�i, <br />q�iP�S/ic�t <br />Additional dates/amounts shall be continued on a separate sheet <br />paper and attached. <br />If the source of the variation which exceeded allowable limits was <br />due to a leak, the incident shall be reported to San Joaquin Local <br />Health District; Environmental Health Division, within twenty-four <br />(24) hours and an unauthorized release report submitted. <br />The quarterly summary report shall be submitted within fifteen (15) days <br />of the end of each quarter. <br />Quarter 1 - January ---------- >March <br />Quarter 2 - April ------------ >June <br />Quarter 3 - Jul ------------- >Se tember <br />-or 4 - October ---------- >December <br />Send to: SAN JOAQUIN LOCAL HEALTH DISTRICT <br />1601 B. Hazelton, P.O. Box 2009 <br />Stockton, CA 95201 468-3420 <br />EH 23 019 10/86 <br />RECEIVED <br />JAN 1 8 1990 <br />ZONMENTAL HEALTH <br />PERMIT/SERVICES <br />