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INVENTORY RECONCILIATION <br />QUARTERLY SUMMARY REPORT FORM <br />Paeility Nave: "I'y zi�1`O��" <br />Facility Address: _ /rf/9 S /t1lA©N� <br />Telephone: 9 yff X95/ <br />Person Filin <br />Report ily <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 Colum 13 of the Loventory Reconciliation Sheet) <br />Inventory variations exceeded the allowable limits for this quarter. t <br />hereby certify under penalty of perjury that the source for the variation <br />was not due to an unauthorised (leak) release. (Yes in Colum 13 of the <br />Inventory Reconciliation' Sheet) <br />List date, tank 1, and amount for all variations that exceeded the <br />allowable limits. <br />Date / Tank I Amount <br />1. !/ C C / e- <br />2. <br />2- <br />3- <br />3. 7/ 3 �- <br />4. <br />S. <br />Additional daces/amouats shall be continued on a separate sheer of <br />paper .and aCtached. <br />If the source of [tie variation uhich exceeded allowable limits vas due to <br />I leak the incident shall be reported to $ J.I. H.D. Environmental llcalth <br />Within 14 hours and an unaurhorazed release report submitted. <br />the Quarterly aunana ry report shall be eaubmit(ed within IS days of the end of cacti <br />QVar(Ir_ <br />Quarter I - January --) N.irch <br />Quarter 2 - April --> June <br />Quarter ) - JoI y --) Jeprrmhrr <br />Quarter 4 - October --) Ovcrmher <br />Send co: SAN JOAQU IN LUCAl. HEA1.1-H D I STK I CT <br />1601 I:. Ha/4-111m, 1' 0. Rox M09 <br />'�l ockton. CA 95201 460-6/81 <br />IJCT 1.0 10/86 <br />