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INVENTORY RECONCILIATION <br />QUARTERLY SUMMARY RFPORT FORM <br />Faeiliey Name: C—�I7hUti C <br />Facility Address: <br />Telephone: <br />Person Fit <br />Reporc <br />ME <br />13 1 hereby certify under penalty of perjury that all inventory variations for <br />the above menCioncd facility were within the allowable limits for this <br />quarter. (No in Colu® 13of the lovenCory Reconciliation Sheet) <br />ElInventory variation& exceeded the allowable limits for this quarter. i <br />hereby certify under penalty of perjury Cha[ the source for the variation <br />was not due to an un■uchorixed (leak) release. (Yes in Cot t3 of the <br />Inventory Reconciliation Sheet) <br />Liar dare,itank f, and amounc for all variations chat exceeded the <br />allowable fimics_ <br />Date �',.'. - Tank I Amounc <br />1. <br />2_ <br />J. <br />6. <br />S. <br />Additional daCes/amounts chall be continued on a separate shccc of <br />Paper and a[taUicd. <br />[f the source of the variation ,which exceeded allowable limits was due to <br />• leak --Che incident shall be reported to S.J L.11 D. Environaicrical. Ilcalth <br />MiChin 24 hours and an unauthorizedrelease rcporc submitted. <br />The Quarterly sum ry rcporc shall be cubAit[ed within Ig days of the end of each <br />quarCrr. <br />-Qa,a rCrr I - January -_) march <br />Q•ia rc�r L - April <br />Qua tier ) - July __) lc pt C,n l.rr t� j„y •''� ��,r ; `�-.V'' r I'I <br />Qu tier 4 - October <br />, <br />Send to: SAN JOAQI)lty L(I(:nl. HEAI:I'H UIS['HICC n' <br />JAN 1", *j <br />1001 E. I:.,r.r•II„,, P.O No.e 2H09 <br />i <br />Stockton. (:n '15201 1,00-6 7 PERMITbl ; VICL-LTH <br />SERVICES <br />0 10/N6 <br />