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,..r` <br />I / INVENTORY RECONCILIATION <br />C QUARTERLY SUMMARY REPORT FORM <br />Faculty Names"1/12c// <br />tacittty:Addres.s . <br />Telephone: - <br />Person Filig <br />Report ,rte" <br />_ l hereby certify under penalty of perjury that all inventory variations for <br />the above mentioned facility vere vithin the allowable limits for this <br />quarter. (No in Column f3 of the Inventory Reconciliation Sheet) <br />Inventory variations exceeded the allowable Limits for this quartet`.' ty <br />hereby certify under penalty of perjury that the source for the verPition <br />was not due to an unauthorized (leak) releise. (Yes in Column 13 of the <br />Laveatory Reconciliation Sheet) <br />List dater tank f, and amount for all variations that exceeded•^tii <br />allowable limits. <br />Date Tank F Amount <br />-z—z <br />z. -/- 1 7 <br />4. <br />s. <br />Additional dateslam uots shall be continued on m eepzrate 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 Ilcalch <br />Within 24 hours and an unauthorized release report submitted. <br />The Quarterly summary rctgrrt shall be submitted within 15 days of the end of each <br />Quarter. <br />Quarter I - January -- h <br />baa ctcr 2 April --> Juuc <br />Quarter 3 - July --) Scptemhcr <br />Quarter 4 - October --) December <br />Send to: SAN JOAQU IN LOCAL HEALI'li DISTRICT <br />1601 E. HazeIlfen. 1'.0. Box /007 <br />SLockton, CA 95201 466-6761 <br />UCT 40 10/80 <br />