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INVENTORY RECONCILIATION <br /> QUARTERLY SUMMARY REPORT FORM <br /> Facility Name: /:/�ti'z (/S/-(��J.fIG''/��t'> Tank i size Product <br /> Jcr <br /> Facility Address: ,QG C S C'4G i<�/Ir✓u1 <br /> C7/(k' a <br /> Telephone : <br /> Person Filing <br /> Report i'�el/ r timet/iY7f/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 /> ElInventory variations exceeded the allowable limits for this quarter. I <br /> hereby certify under penalty of perjury that the source for the variation <br /> vas not due to an unauthorized (leak) release. (Yes in Column 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 /> I. <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 whichexceeded 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 --> March <br /> Quarter 2 - April --> June <br /> Quarter 3 - July --> September <br /> -- -- <br /> Quacter 4 - October --) December <br /> Send to: SAN JOAQUIN LOCAL HEALTH. DISTRICTPIETRO <br /> 1601 E Haze1tnn , P . 0 . fox 2009 <br /> Stockton , CA 95201 466-67b1 '" J O7 <br /> UCT 40 10/86 <br /> ENVIROMENTAL HEALTH <br /> FERMIT/SERVICLS <br />