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INVENTORY RECONCILIATION JUL <br />QUARTERLY SUMMARY REPORT FORM 191989 <br />L"4Y1R0NMr&,TA R <br />Facility <br />Facility Address: <br />Te lephone : 03 '1 - r i 5 r7,'5- <br />Person <br />7•�Person F ling <br />Report ` A _ (`, �-_.� - <br />Tank # <br />Product <br />�0 <br />, , - <br />' r 1 Y7 i e <br />11/F:L <br />0 I 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 />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 />T <br />Inventory RAconciliatiion thsst) <br />List dates tank #, and amount for all variations that exceeded the <br />allowable limits. <br />Data T.n: ,Amount <br />f? <br />Additional dates/amounts shall be continued on a separate sheet of <br />paper and aetacbed. <br />If the source of the variation which exceeded allowable limits was due to <br />a leak the incident shall be reported to S,J.L.H.D. Environmental Health <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 - January March <br />Quartsc 2 - April --� June <br />Quarter 3 - July --> September <br />Quarter 4 - October •-> December <br />Send to: SAN JOAQU1N: LOCAL. HEALTH DISTR�CT <br />1601 E. ' T{azelton, -P.O. Box 2009 <br />Stockton, CA 95201 466-6781 <br />UGT 40 10/86 <br />