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• <br />• <br />INVENTORY RECONCILIATION <br />QUARTERLY SUMMARY REPORT FORM <br />Facility Name: SIM i <br />Me (30 <br />Pacility Address: "KAti <br />Telephone: _LE,) 3b�b-ii'17 <br />Person Filing <br />Report <br />Tank / Site <br />2 in <br />Product <br />a$4, u,al <br />n <br />RLeC-'D <br />)-l- <br />, U#J <br />/ 2- �" I <br />W-2-Du--et--i <br />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 unauthorised (leak) releise. (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 />2. <br />3. <br />4. <br />5. <br />p7�1 <br />j <br />k <br />L.: P <br />ENVIR"'LAIAL HFALrH <br />FERMIT/SERVICE., <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 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 />artcr I �-Apri <br />anuary --) March <br />1�7—Q'1arter 2 I —i utQuartet�cptcmbrr <br />Quarter 4 - October --> December <br />Send to: SAN JOAQUIN LOCAL HEALTH DISTRICT <br />160L 1:. Haze 1 t0►n , P.O. Box 2009 <br />Stockton, CA 95201 466-6781 <br />IICT 40 10/86 <br />A- <br />