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0 R En('�'117 11 �11 Em D <br /> OCT 0 2 1992 <br /> INVENTORY RECONCILIATION ENVIRONMENTAL HEALTH <br /> QUARTERLY SUMMARY REPORT FORM PERM IT/Mvi pr--% <br /> Facility Nasse: <br /> Tank I I <br /> Size Product <br /> Facili.ty -Address: J 10 <br /> f�V <br /> Ica <br /> Telephone : &vq) qS1-1000 <br /> Person Filing <br /> Report J"/'W /I A//7 <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. (mo 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) relea' se. (yes in Column 13 of the <br /> Inventory Reconciliation Sheet) <br /> List date, tank f, and amount for all Variations that exceeded the <br /> allowable limits. <br /> Date Tank f Amount <br /> 1. <br /> 3. <br /> 4. <br /> s. <br /> Additional dates/amounts shall be continued on a separate sheet of <br /> paper and attached. <br /> It 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 I - January Harch <br /> Q*Aartcr 2 - April June <br /> Quarter 3 - July September <br /> Quarter 4 - October Dj.crmt)er <br /> Send to: SAN JOAQUIN LOCAL HEALTH DISTkICT <br /> 160L E' . lllazeltfiat , P . O . [i()x 2()()g <br /> SLockLon , CA 95201 466 - 6781 <br /> JGT 140 10/ 86 <br />