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INVENTORY RECONCILIATION <br />QUARTERLY SUMMARY REPORT FORM <br />Facility Name: �� /�/� LAKs �!' 101.,1-2o� <br />Facility Address: hp/ /), ���'//{�A„J Z/V <br />Telephone: <br />Person Filing <br />Re o r 1-tX /A'/ <br />Tank # Size Product <br />O l i <br />P N �w y G �.�• - �j <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 unauthorized (leak) release. (Yes in Col,= 13 of the_` <br />Inventory Reconciliation Sheet) <br />List date, tank #, and amount for all variations that exceeded the <br />allowable limits. <br />Date Tank # Amount <br />1., 3 %�5 0� P, -'a.5 �- c,o /,6,�9t-t <br />2. Coeeec�l - 11 PIP OR <br />-t"7 <br />3. /2 3/ 3 Rcloi <br />4.6�Q .9,,)�AIA' <br />P1no« <br />115190 <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 ileal th <br />within 24 hours and an unauthorized release report submitted. <br />The quarterly su!.xxnary report shall be submitted within 15 days of the end of each <br />quarter. <br />Quarter I - 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.O. Box 2009 <br />Stockton, CA 95201 466-6761 <br />UCT 40 10/86 <br />