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INVENTORY RECONCILIATION <br />QUARTERLY SUMMARY RFPORT FORM <br />Facility Hamc:C� 62UVE f'AiZC <br />racility <br />Telepho <br />Person <br />Report: <br />QL hereby certify under penalty of perjury that all inventory variations for <br />the above ocnrioned facility -ere within the allowable limits for Chin <br />Quarter_ (Ho in Colum 13of the Inventory Reconciliation Sheet) <br />QInventory variations exceeded the allowable limits for Chia quarter. I <br />hereby certify under penalty of perjury that the source for the variation <br />was not due Co an unauthorized (leak) release. (Yes in Colus=n 13 of the <br />Inventory Reconciliation Sheet) <br />List dacc'itank /, and aasounC for all variations chat exceeded the <br />allowable limits. <br />-Datet+:,', Tank ' Amount <br />1. <br />3. <br />4. <br />S. <br />Addicioaal daces/amouacs chall be concioucd on a •eparace sheet of <br />paper.and attached_ <br />If the source of Che variac ion -hich exceeded allowable IimiCz as due Co <br />a leak the inczdcnc shall be reported to S .L.H.D. Envic0rm ncal Health <br />within 24 hours and an unauChorized release rcporC submitted. <br />The Quarterly suamary rcporC shall be s•.bmitted within IS days of the end of tach <br />quarter. <br />-Qi.a rCrr I - Januwry --) March <br />Q•u rtrr 2 - April --> Jun.. <br />Quarter I - J..Iy __> Scpccmh.:r <br />-Q.arccr 4 - October --) G cembcr <br />Scnd to: SAN JOAQUIN LOCAL HEAI:I'li DISI-HIC1. <br />I601 1.. Hass• I t .ui , V,0. 14nx 1(1(17 <br />SLockcon, (.A 95101 1-66-6781 <br />0 10/N6 <br />