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INVENTORY RECONCILIATION <br /> QUARTERLY SUMMARY REPORT FORM <br /> Facility Name: ZOf 4,1 700' , de fi Tank I Size Product <br /> Facility Address: ,?DQ <br /> v �CR�7 00 <br /> Telephone : <br /> Person FiZ-1-94 <br /> }-�g <br /> Report /G�a4 >` <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 /> E] Inventory 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 an unauthorized (leak) release. (Yes in Colum 13 of the <br /> Inventory Reconciliation Sheet) <br /> List dater tank f, and amount for all variations that exceeded the <br /> allowable limits. <br /> Date Tank I Amouat <br /> I. <br /> 2. <br /> 3. <br /> 4. <br /> S. <br /> Ad4ditionsl dates/axaotn 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 ..) L . H . D . Environmental Health <br /> within 24 hours and an unauthorized release report submitted. <br /> The quarterly sumou ry report shall be submitted within 15 days of the end of each <br /> quarter. <br /> Quarter I - January --) March 1. m <br /> QQiar[er 2 - April --) June <br /> 4-arter ) - Ju I __> is p[Cmher N <br /> Q%,arYcr 4 - October --> H.•cembcr 1% <br /> Send to: SAN JOAQUIN LOCAL HEA1.1-h DISI It ICI TV <br /> � \�jVLL <br /> 1001 E . Hnzt• II -n , i' . n it„ .: /M 21 � <br /> EP <br /> Stockton , (:A 11 )201 /.l,i, - (Ilbl Sl{EAISN <br /> 1:'14( 10/ 86 <br /> ENVI W1 ISE ICES <br />