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All <br /> L 1 <br /> INVENTORY RECONCILIATION <br /> S U i � 1989 <br /> QUARTERLY SUMMARY REPORT FORM EN' IRO""'EWALNEAl.1H <br /> PERW ISERVICES <br /> FaciLity Haase: ~� Tank t Si=e product <br /> !'acilaty -Address: <br /> Telephone : /� _ , <br /> Person Filing <br /> Report , ✓ . <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 130f the Inventory Reconciliation Sheet) <br /> ElInventory 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 /> Inventory Reconciliation Sheet) <br /> List date, tank f, and amount for all variations that exceeded the <br /> allowable limits. <br /> Hate Tank f Amount <br /> 1. <br /> 2. <br /> 3. <br /> 4. <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- exceeded allowable limits was due, to <br /> A leak the incident shall be reported to S .J . L. H p . Environmental Health <br /> wtithin 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 --> Hirch <br /> Quarter 2 - April -> .lune <br /> Quarter 3 - July --) Septemhr.r <br /> Qtiarcer 4 - October --) December <br /> Send to: SAN JOAQU IN 1,()(;(11, HEALTH DISTRICT <br /> 160t 1-: . ]para 1 1 ()re , 1' - O . 13()x �()()`} <br /> SLockton , (.*A 05201 4 6 6 -6 7 b I <br /> l)(,'1' 140 10/ 86 <br />