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INVENTORY RECONCILIATION UCT 18 ,1989 <br /> 4�1 <br /> QUARTERLY SUMMARY REPORT FORM <br /> ENVIRONMENTAL HEALTH <br /> Facility Name : F.leyto Z PERMIT/SE ICES <br /> Tank # Size Product <br /> Facility Address : 2"I DVin ' Dr i t� O � cic <br /> CACI . � GSZOI 2. Pv-ermiu <br /> Telephone : 2C-)q gcj)2-35+3 1 <br /> Person Filing <br /> Report : D1 a.Cl-a. �ar <br /> [ ] I Hereby certify under penalty of perjury that all inventory <br /> variations for the above mentioned facility were within the allowable <br /> limits for this quarter. (No in Column 13 of the Inventory <br /> Reconciliation Sheet ) . <br /> [V*J"'Inventory variations exceeded the allowable limits for this quarter. <br /> I hereby certify under penalty of perjury that the source for the <br /> variation was not due to an unauthorized ( leak) release. (Yes in <br /> Column 13 of the Inventory Reconciliation Sheet ) . <br /> List date, tank # , and amount for all variations that exceeded the <br /> allowable limits . <br /> Date Tank # Amount <br /> 1. <br /> 2 . <br /> 3 . <br /> 4 . ? Al�i <br /> 5 . <br /> Additional dates/amounts shall be continued on a separate sheet of <br /> paper and attached. <br /> If the source of the variation which eX,ceeded allowable limits was due <br /> to a leak the incident shall be reported to S .J.L.H.D. Environmental <br /> Health within 24•-hours and an unauthorized release report submitted . <br /> The quarterly summary report shall be submitted within 15 days of the <br /> end of each quarter. <br /> Quarter 1 - January --> March <br /> Quarter 2 - April --> June <br /> Quarter 3 - July --> September <br /> Quarter 4 - October --> December <br /> Send to: SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. Hazelton, P. 0. Box 2009 <br /> Stockton, CA 95201 466-6781 <br /> T 40 10/86 <br />