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INVENTORY RECONCILIATION <br /> % QUARTERLY SUMMARY REPORT FORM <br /> r <br /> Facility Name �i;��� �c<ii/3i CL��afC l�-lce Tank # Size Product <br /> Facility Address: ZOO/ A' 9-/ ✓ IT, <br /> Telephone : <br /> Person Filia <br /> Reports>,iyC TL'Oec T. <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 so unauthorized (leak) release. (Yes in Column 13 of the !' <br /> Inventory Reconciliation Sheet) <br /> List date, tank t, and amount for all variations that exceeded the <br /> allowable limits. <br /> Date Tank l Amount <br /> 1. <br /> 2. <br /> 3. <br /> 4. <br /> S. <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 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 /> atter 1 - January --> Narch <br /> Qiarter = pri --> June <br /> a Cvl Quarter 3 July --> September <br /> Quarter 4 - October --> December �� �„j , f <br /> Send to: SAN JOAQUIN LOCAL HEALTH DIS'1'HICT iVl <br /> 1601 G . Hazelton , P .O . Box 2009 VV APR 01 1988 <br /> Stockton , CA 95201 466-6781 ENVIROMENTAL HEALTH <br /> UG'I' 40 <br /> 10/ 86 PERMIT/SERVICES, <br />