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INVENTORY RECONCILIATION <br /> QUARTERLY ///SUMMARY REPORT FORM <br /> /ISS ��J. Size Product <br /> Facility Name: ���jiti,�. -� - <br /> Facility Address: 1£rOC, S x-46 <br /> 70 C.c' <a'r' <br /> i <br /> Telephone : 7/ Y/-g3(� / <br /> Person Filing <br /> Report X31 c i�Ec-l�+Iil,� <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 /> 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 i, and amount for all variations that exceeded the <br /> allowable limits. <br /> Date Tank I 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 al-lovable limits was due to <br /> a leak the incident shall be reported to S .J .L. H . D. Environmental Health <br /> Mithin 24 hours and an unauthorized release report submitted. <br /> The quarterly summery report shall be submitted within 15 days of the end of each <br /> quarter. <br /> Quarter 1 - _January --> March .' <br /> Quarter 2 - April --) June t , <br /> Quarter 3 - July --> September <br /> Quarter 4 - October --> December <br /> Send to: SAN JOAQUIN LOCAL HEALTH DISTRICT, OEC 3 0 °nc7 <br /> 1601 E . Hazelton , I3 .0 . Box 2009 WPLTH <br /> Stockton , CA 95201 466-6781 fNVIRO PERMIT-C <br /> UCT 40 10/86 < <br /> /gEHVI�-� <br />