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INVENTORY RECONCILIATION JUL I I <br /> £p, <br /> QUARTERLY SUMMARY REPORT FORM ENVIRONMENTAL HEALTH <br /> • E I / VI <br /> Facility Nage: c <br /> _ Tank I Site <br /> Product <br /> Fac . ity Address- 1,o 3,1 <br /> Telephone : <br /> Person F ' 1 i n g —'----- <br /> Report <br /> ® I hereby certify under penalty of perjury that all inventoryva <br /> ri <br /> the above mentioned facility were within the allowable lims foratithiss For <br /> quarter_ (No in Column 13 of the Inventory Reconciliation Sheet) <br /> Inventory variations exceeded the allowable Limits for this <br /> quarter. <br /> hereby certify under penalty of perjury that the <br /> was not due source for the variacioa <br /> 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 <br /> Allowable limits. the <br /> Date Tank # Amount <br /> 2. <br /> 3. <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 s due to <br /> wa <br /> a leak the incident shall be reported to SJ . L. H . D. Environmental Elealeh <br /> was3 <br /> Within 24 hours and an unau[horizcd release report submitted. <br /> The quarterly summary report shall be .ubmi [ted within 15 days of the end of ractt <br /> quarter <br /> Qua rt-4e-r---Il - January --� Harch <br /> < "'" larCer - April --> Jurae <br /> Quarter 3 - July --> September <br /> Quarter 4 - October --> December <br /> Sen<9 to: SAN JOAQUIN LOCAL HEALTki DISTRICT <br /> 1601 E . Hazelton , P .O . Box 2009 <br /> UCT 40 10/86 Stockton, CA 95201 466-6781 <br /> A <br /> 7. <br />