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INVENTORY RECONCILIATION ✓�/�y - 57��2 <br /> QUARTERLY SUMMARY REPORT FORM <br /> Facility Name: ✓�n7Z7 Tank 1 Size Product <br /> Facility Address: 3'"-v RAJ tivlt99f�J <br /> Telephone : -/65=76/6 <br /> Person Filing <br /> Report STf�E rl�EG6E/L <br /> I hereby certify under penalty of perjury that all inventory variations for <br /> the above (No ifacility were within the allowable limits <br /> e1 <br /> quarte[. (No inn Co Colu® 1)of the inventory Reconciliation She <br /> t <br /> DInventory variations exceeded the allowable limits for this qusrtei�N 1 6 13-qc <br /> hereby certify under penalty of perjury that the source for th�,V� f1`AL HEALTH <br /> was not due to an unauthorized (leak) release. (Yes in Column @€RM14/SERVICES <br /> Inventory Reconciliation Sheet) <br /> List date, tank /, and amount for all variations that exceeded the <br /> allowable limits. <br /> Date Tank E Amount <br /> 1. <br /> 2. <br /> ). <br /> 4. <br /> 5. <br /> Additional dates/amounts shall be continued on a separate sheet of <br /> paper and attached. <br /> Ir <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 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 - Jaouary --) March <br /> Quarter 2 - April --> June <br /> Quarter ) - July --> September <br /> Quarter 4 - October --> December <br /> Send to: SAN JOAQUIN LOCAL HEAL1'li DISTRICT <br /> 160L E . Hazelton , P .O . [lox 2009 <br /> Stockton , CA 95201 466-67bl <br /> UCT 40 10/86 <br />