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INVENTORY RECONCILIATION <br /> QUARTERLY SUMMARY REPORT FORM <br /> Facility Name: �(�Joj4� rjJ d.i Tank t Size Product <br /> i. <br /> Facility Address: '167 <br /> Telephone : <br /> Person Filf g <br /> Report 14444 �y <br /> 0---`lhereby Certify under penalty of perjury that all inventory variations for <br /> the above mentioned facility were within the allowable limits for this O <br /> quarter. (No in Column 13of the Inventory Reconciliation Sheet) <L <br /> ��� <br /> ElInventory variations exceeded the allowable limits for this quar \\\i <br /> hereby certify under penalty of perjury that the source for thion <br /> Inventorwas not y Reconciliatione to an orized 5heet)(leak) release. (Yes in Column IJ;oe��,� <br /> List date. tank /r and amount for all variations that exceeded tS <br /> allowable limits. <br /> Date Tank I Amount <br /> 1. <br /> 2. <br /> ]. <br /> 4. <br /> 5. <br /> Additional dates/amounts 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 ..I . I, . H . D . Environmental Ilcalth <br /> within 24 hours and an unauthorized release report submitted. <br /> The quarterly sumnury report shall be submitted within 15 days of the end of each <br /> quarter. <br /> x <br /> Quarter I - January --) March 4*5 <br /> QQiarter 2 - April --> June to <br /> Quarter ) - July --) Jepcember 0% <br /> Quarter 4 - October --) december 1% <br /> Send co: SAN JOA QU IN LOCAL HEA1.1'1i OI S-I H I C'I <br /> 1001 E. . Hazel l nn , 1' .O K.'x 2()()'1 <br /> Stockton , CA '/')201 461, 01bl <br /> t4:'f /'0 Ill/ bh <br />